Why documentation is so important
a legal obligation to document
the use of bedrails and assistive devices
Documentation of medication administration is important in client safety, as it prevents the likelihood of duplicate administration
For example, a quality improvement study could reveal high rates of incident reports related to falls, which could prompt in-service or training sessions surrounding the prevention of falls
There is also a saying: “if it’s not documented, it wasn’t done” – your documentation notes must be complete, or it will be presumed that care was not provided.
For example, influenza-related hospital admission rates and mortality rates are recorded and tracked each year
Documentation is critically important in cases that involve violence because the client record may be used as a source of evidence in legal proceedings
Glasp is a social web highlighter that people can highlight and organize quotes and thoughts from the web, and access other like-minded people’s learning.