Nurses face constant challenges in their day-to-day jobs. When you’re dealing with emergencies and sick patients, legal issues may not be at the forefront of your mind— but they should be.
Running into legal problems can put your nursing license at risk, but what can you do to inform and protect yourself? Lawyers experienced with nursing license defense can help.
Proper Documentation Is Key
Maintaining accurate patient documentation is one of the most routine and important tasks nurses perform. This documentation allows multiple care team members to have access to necessary information so that these medical professionals can provide continuity of care.
Documentation also offers proof of which treatments patients need and later receive to justify reimbursement from insurance companies. At the same time, it helps nurses prove that they have met all regulatory and legal requirements. That helps your employer and ensures that you comply with facility policies.
Maintaining appropriate documentation is crucial to protecting yourself from malpractice claims, and it is one of the most important nursing license defense strategies you can adopt.
Improving and Ensuring Accurate Documentation
Remember to prepare documents in a timely manner to ensure that you are offering the most accurate information. Promptness can help avoid problems ranging from medication errors to accusations of improper care.
Include as much information as possible. Document all details related to patient care, from assessments, medications, interventions, and outcomes.
You should always use factual and objective language when adding patient information. It’s essential to avoid any hints of personal bias. Don’t use words that make it seem as if you’re being subjective in your annotations.
If a patient experiences adverse effects from medications or interventions, you need to document these. Even if they were minor events, leaving a record is important. This record keeps patients safer and protects you legally, too. It can also help the facility and other caregivers improve their care in the future.
Use the correct and standard abbreviations in your notations, and be consistent. Stick to the same format for each document to ensure clarity and avoid any confusion.
Receiving patient consent is one of the most crucial aspects of providing care, so you need to document this, too. Leave a record of informed consent and note whether the patient clearly understood what to expect from treatment.
Nursing License Defense: Getting the Help You Need
If you’re dealing with a nursing license issue or complications with the State Board of Nursing, the best thing you can do is to reach out to an experienced nursing license defense lawyer.
At S J Harris Law, we offer the guidance you need when facing legal challenges in California. You shouldn’t have to undertake nursing license issues on your own. Contact S J Harris Law today to learn more about how we can help you get justice.
