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Do's and Don'ts of Nursing Documentation
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Nurses are well aware of the standard, which states that if a certain matter affecting patient care is required to be charted and it is not, the overwhelming presumption is that it may not have been done. Good documentation will help you defend yourself in a malpractice lawsuit, it can also keep you out of court in the first place. The following excerpts are courtesy of NSO Risk Advisor-January, 1977.
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http://www.medi-smart.com/documentation.htm
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