Does your documentation defend or discredit?

Abstract

Documenting medical records is often done hurriedly; it is a last responsibility before the patient is discharged, sometimes after the shift has actually ended. What seemed so clear at the time it was written may be barely legible, unbelievably incomplete, and perhaps legally indefensible later. The patient's chart is a permanent legal record that can powerfully defend or easily discredit the nurse when questions arise. A documentation review could be time well spent.