Documentation of our assessment

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In this era, it seems as if everyone is sue happy. Documentation of our assessment is vital for assuring a court of law that we did something. In 2008, CMS has passed a law that they will not pay a hospital when a patient develops a bed sore or a urinary infection while hospitalized for something else. My institution has learned the value of documentation. If we fail to chart that a bedsore already existed on admission, we will not be paid. This is really an eye opener for the admission nurse. Sometimes a nurse in a hurry would not turn the patient over and examine their back side. We do a thorough exam now. It must be documented and noted or it essentially was never done in a court of law.

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