The Importance of Accurate Documentation for Forensic Nurses

I had many occasions to be involved with child protection services (CPS) and adult protection services (APS) while working as a community health nurse and in hospice. My dealings were by no means something I was formally taught, however it was quite apparent that careful, concurrent, and accurate documentation was of most importance.

The documentation of behaviors, diagnostics ordered and provided, any wounds or injuries, and verbal interactions was painstakingly undertaken. In essence, I created a paper trail so each interaction was documented by date and time.

Public health nurses and other nurses who work in the community deal with many who are vulnerable and at risk. Forensic nursing can be of great assistance and should be a course covered by these nurses in order to assist them in dealing with situations involving harm. Using unambiguous language, documenting all interactions with any involved in the case, and obtaining clinical data to present a clear picture of the problem/incident assists in the pursuit of an desirable outcome.

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