Documentation of our assessment


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.


Tags: ,

Leave a Reply

Please log in using one of these methods to post your comment: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: