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Nurse Documentation: Not Done or Worse,

Done the Wrong WayPart I

Marilyn Frank-Stromborg, EdD, JD, ANP, FAAN,
Anjeanette Christensen, BA, and David Elmhurst Do, BS

Purpose/Objectives: To focus on nursing documentation

and expanding technologies (e.g., facsimile, telephone, email, computer charting) that offer different ways to
record, deliver, and receive patient records and avoid
nursing liability for inadequate or inaccurate documentation.
Data Sources: Nursing, non-nursing healthcare, legal
journals, case law, and related Internet sources.
Data Synthesis: To avoid liability for inadequate or inaccurate documentation, nurses must be aware of the major issues involved in documentation litigation. New technology is altering how healthcare documentation is done
and raising new confidentiality issues.
Conclusions: Nurses should follow their facilitys guidelines and principles for documentation of patient care, especially when using more advanced technologies.
Implications for Nursing Practice: Educating nurses
about the principles of documentation and the importance of implementing risk-reduction practices will help
guard against liability and ultimately improve patient care.

lthough the medical field has progressed significantly

in detecting and treating cancer, more work needs to
be done. Oncology nurses play a vital role in cancer
prevention, detection, and treatment. Their responsibilities
include working directly with the patients and providing documentation in patient records. In past years, documentation may
not have been considered a very important part of a nurses
job. Today, what a nurse writes on a medical record or types
into the computer in regard to the patients care is important
to more than just the patient.
Oncology nurses in the healthcare system, which is becoming more sophisticated, are not only concerned that patients
receive proper care but also have to consider liability resulting from improper documentation. The number of negligence
and malpractice lawsuits that name nurses as defendants because of their failure to adequately document patient care has
increased in recent years. Nurses are under a great deal of scrutiny, regardless of the healthcare setting. For example, in the
clinical trials setting, where documentation is critical to the
evaluation of the experimental treatment, a greater emphasis
is placed on correct documentation procedures and the increased role of risk managers as a result of litigation concerns.
The work of the oncology nurse, whether in the hospital,
home, or clinical trials setting, involves a great deal of documentation, such as charting the patients history, physical
changes, medications, treatments, chemotherapy administration, side effects, complications, family concerns, and tele-

Key Points . . .
New technology offering different ways to record, deliver,

and receive patient records (e.g., facsimile, telephone, email, computer charting) poses serious documentation and
legal issues for nurses.
Nurses must be knowledgeable about the risk factors associ-

ated with the emerging electronic technologies related to

nursing documentation and confidentiality expectations and
implement risk-reduction practices when using these new
methods of communication.
Various intrinsic and extrinsic reasons account for why

healthcare professionals do not adequately document care.

Nurses who follow their facilitys guidelines on documenta-

tion are more likely to provide an accurately documented patient record and, as a result, better patient care.

phone conversations. The demand for oncology nurses involved in these activities can leave a paper trail that would take
others months, or even years, to follow and understand. Nurses
need to understand the laws as they apply to documentation
and be familiar with the issues that have a substantial impact
on their nursing role.
Adding the increased use of and reliance on technology in
the nursing setting complicates matters even further because liability can result from the nurses improper documentation
when using these new technologies. Changing technology is
stretching the parameters of documentation and the concerns
related to adequately documenting care. Fortunately, oncology
nurses can do several things to ensure effective patient care
and proper documentation.
This article discusses the various methods and forms of
documentation used by nurses and provides guidelines for the
proper documentation of a patients chart. Reasons why some
nurses do not adequately document care also are discussed.
The article focuses specifically on the widespread use of
emerging technology and its impact on patient charting and
Marilyn Frank-Stromborg, EdD, JD, ANP, FAAN, is the chair and
presidential research professor in the School of Nursing, and
Anjeanette Christensen, BA, and David Elmhurst Do, BS, are thirdyear law students in the College of Law, all at Northern Illinois University in DeKalb. (Submitted January 2000. Accepted for publication September 13, 2000.)



provides suggestions for proper documentation practices when

using these different technologies.

General Principles of Documentation

Documentation has undergone a great deal of change
through the years. Many different methods have been developed and used for charting a patients care, and some have
been more effective than others. Most forms of documentation fall into one of two categories: documentation by exception and documentation by inclusion (Coleman, 1997).
Documentation by exception means that standardized questions are asked, but negative answers do not have to be recorded (Coleman). For example, if the patient responds affirmatively to the question Do you have chest pain?, then
it would not be necessary to note that the patient was not
sweating or had no shortness of breath (Coleman). On the
other hand, a nurse using documentation by inclusion would
make note of negative responses by the patient and any other
questions asked that are not part of the standardized format
(Coleman). Comparing the two methods indicates that documenting by exception has several more advantages than
documenting by inclusion (see Table 1). This does not necessarily mean that the former is the better method because the
two disadvantages of documenting by exception can be very
devastating to nurses who are testifying about their documentation practices.
Regardless of the method chosen, documentation comes in
the form of a patient record and includes nurses notes. A patient record is to be a complete and accurate account of a
patients care (Brent, 1997). The primary purpose of a record
is to identify a patients status to document the plan of care
needed. A plan then can be developed to deliver and evaluate
that care (Aiken & Catalano, 1994).
A medical record has various uses. Within the healthcaredelivery system, a record is used to communicate among staff
members, departments, and other healthcare providers concerning the patient and the patients care (Brent, 1997). The
systems risk-management department, utilization review
board, and quality assurance committees use a patient record
to evaluate patient care and its necessity and to determine
where improvements are needed (Brent). Outside the healthcare-delivery system, a patient record is used by private and

governmental third-party payors, including Medicare and

Medicaid, by researchers in health care, and by healthcare administrative agencies for initial and continuing accreditation or
licensing grants (Brooke, 1997).
A record also may serve as a communication tool for individuals who are not directly involved in the healthcare community. Documentation recorded by nurses is a critical factor
from a patient-outcome perspective, a continuous quality improvement perspective, and a legal-ethical perspective (Aiken
& Catalano, 1994). A nurses documentation also is important
in determining who pays for the medical care (Wisser, 1998).
For example, in an analysis of the views of the people who
often have an interest in a patients care and treatment, the
medical providers most likely will promote appropriate treatment and prompt return of the patient to functional independence; the attorneys will stress illness and disability; and the
payors will tend to push for economizing costs (Wisser). In
their efforts, these people will scrutinize all of the documentation for evidence that supports their perspective (Wisser).
The documentation that correctly follows the facilitys guidelines will support the nurses perspective.
Documentation guidelines can vary at each facility. Standard governing documentation comes from various sources,
such as federal and state laws. Guidelines should be checked
at the nurses particular facility, but some general guidelines
should be remembered when recording information in a medical record. Buppert (1999a) suggested that nurses in any setting follow these principles.
1. The patient record should be complete and legible.
2. The documentation of each patient encounter should include
The reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
An assessment, clinical impression, or diagnosis
A plan for care
The date and legible identity of the observer.
3. If not documented, the rationale for ordering diagnostic and
other ancillary services should be inferred easily.
4. Past and present diagnoses should be accessible to the treating and consulting physician.
5. Appropriate health risk factors should be identified.
6. The patients progress, response to and changes in treatment, and revision of diagnosis should be documented.

Table 1. The Two Most Frequently Used Documentation Methods




Documentation by exception

Reduces paperwork
Less time consuming
Reduces repetition of charting
Provides immediate identification of changes
in patients condition
Nurse does not look negligent for anything not

Very difficult to prove that the standardized

questions were asked and what the
patients actual responses were
In the presence of unclear guidelines or a
lack of other flow sheets, a legal interpretation of a breach in the standard of care will
be made.

Documentation by inclusion

Produces a very complete and thorough patient record

If presented in court, it appears as a complete record of events.

Very time-consuming
Creates additional paperwork

Note. Based on information from Coleman, 1997; Meiner, 1999a, 1999c.

ONF VOL 28, NO 4, 2001


Nurses who follow these six principles, as well as their

facilitys guidelines on documentation, will provide an accurately documented patient record. Following the principles will
be beneficial to nurses, patients, other staff members, and anyone else who may need to look at the patients chart. Unfortunately, the existence of guidelines does not ensure that nurses
will engage in proper documentation practices.

Research on Why Nurses Do Not

Adequately Document Care
Healthcare professionals do not adequately document care
for various reasons. Brooks (1998) identified some extrinsic
or environmental barriers, such as having a heavy-patient load,
insufficient staffing, cumbersome charting formats, and lack of
time. Often, nurses will find themselves in a situation where
they are so busy that they just forget to document various details that are essential to accurate documentation and care.
Intrinsic barriers to adequate documentation consist of inherent or internal influences on behavior. Nurses have implied
that they had neither the language nor motivation to write
about behaviors or nonphysical concerns in the clinical record
(Brooks, 1998). Nurses tend to use redundant forms and imprecise language in their reports because the nursing community lacks a distinct professional identity and language as demonstrated by the inconsistency and devalued documented
evidence of their care (Brooks). Intrinsic barriers also include
norms that seem to favor the communication of mundane or
routine aspects of care and nurses lack of confidence in expressing clinical judgments and decisions (Brooks). Another
reason for incomplete documentation is that nurses do not always chart what seems to be obvious treatment or care of a
patient. Nurses dangerously assume that the person reading the
chart will know that a procedure or treatment probably was
performed because it is so fundamental. Sometimes, the issue
of sloppiness or cutting corners enters into why nurses do not
adequately document what they have done.
Other healthcare professionals do not adequately document
care because they lack the necessary writing skills (Brooks,
1998). Some healthcare professionals are just too embarrassed
by their writing ability, and they oversimplify what they are
charting or they just write what they know. The oral culture of
the nursing practice can render a perfectly capable nurse incapable when it comes to documentation (Brooks). Nurses have
yet to define how best to discover and articulate their clinical
focus, concerns, and actions into writing. Their actions are
typically described as compassionate, committed, and caring,
yet these attributes often are difficult to recognize in the nursing documentation. Verbal accounts of patient care situations
were far richer than the recorded data (Brooks). Another reason for the lack of writing skills, especially today, is reliance
on the computer. Sometimes, nurses are so accustomed to typing or computer charting that they have trouble writing.
These reasons should not be excuses for inadequate documentation but should serve as a learning tool for nurses.
Nurses may not realize that they are developing poor documentation patterns in a patients record. Nurses who are familiar with what is causing or leading to poor documentation can
evaluate their own documentation practices and discover possible weaknesses, thereby improving the overall quality of
documentation and level of care for patients. Nurses should

evaluate their documentation practices even if they are using

a documentation method other than the paper medical chart.

With the ever-increasing advancements of technology come
different ways to record, deliver, and receive patient records,
which often raises patient confidentiality concerns. Confidentiality is a legal and ethical issue for nurses. It is a part of the
American Nurses Associations (1985) Code of Ethics and
appears in patients bill of rights (Nurses Service Organization
[NSO], 1999). According to these documents, nurses are expected to perform assessments and treatments discreetly and
to treat all communications and records as confidential (NSO).
Nurses in all settings should take special considerations into
account when using new technology that includes facsimile
(fax) machines, computers, and telephones.

Breaches of confidentiality exist when a nurse uses a fax
machine in an area that is not limited to the individuals access (Aiken & Catalano, 1994). Problems that can occur
from using a fax machine include the transmission of confidential information to the wrong person or receiving the information from the wrong person or the wrong facility. This
can occur by simply misdialing the fax number. A nurse who
misdials a fax number when sending information probably
will be unable to track down where the message was sent. If
the sender is able to find the receiver of the information, the
damage has been done because the confidential information
already is disseminated. To find out where a fax was sent, a
nurse must check the fax machines internal log. If the information went to the wrong number, the nurse must send another fax to that number asking the recipient to destroy the
material (NSO, 1999).
Nurses should refrain from faxing information that is highly
confidential, such as HIV and HBV tests or status reports
(Aiken & Catalano, 1994). A member of Congress had her
medical records unintentionally faxed to the New York Post the
night before her primary, and the New York Post proceeded to
publish the details about a prior suicide attempt (Jurevic,
1998). If possible, mailing information might be a better alternative to protect a patients confidentiality.
Policies and procedures must be developed regarding the
types of information that can be faxed. Although these problems cannot be completely eliminated, nurses can take safety
measures. The American Health Information Management
Association recommends that nurses first check to be sure that
the fax number is correct before dialing, check again on the fax
machine display, and check once again before pressing the
send button (NSO, 1999). The association also recommends
that nurses do the following.
Ask the recipient to send a return fax verifying receipt of the
Call the place of delivery to let someone there know material is being sent and to confirm that it was received.
Always fill out a cover sheet before sending it with the information that is to be faxed.
The cover sheet should indicate if the information is confidential.
A doctors orders received by fax should be verified according to hospital protocols. In the absence of guidelines,



nurses should use whatever means necessary to confirm the

order (Karch & Karch, 1999).
Nurses should never read a fax that is not addressed to them,
even if it appears to be in regard to one of their patients.
Nurses should never send faxes containing confidential patient
information to anyone outside of the healthcare-delivery system unless the patient gives his or her consent.
Fax machines should be placed in areas where only the
people who will use them have access. If possible, only one
person should be in charge of the general maintenance of the
machine, the delivery of incoming faxes, and the fax activity
reports that are printed. Having one person operate the fax machine would limit the facilitys potential of being named in a
lawsuit for breach of confidentiality.

Telemedicine is changing the healthcare-delivery system,
and its rapid expansion is raising questions regarding the application of traditional legal principles to the system (Granade,
1997). Nurses who use the telephone to take orders or give
patients instructions should be aware of the concerns that may
arise and should know how to effectively address them. Nurses
who treat patients with cancer, particularly in the outpatient
setting, need to be careful because patients frequently will call
in with problems caused by chemotherapy and radiation treatments. Some hospitals prohibit telephone orders related to
dangerous medications such as chemotherapy (Fiesta, 1994).
A seemingly simple request, like a prescription renewal, can
pose serious risks both to the patient and the nurse handling
the call. For example, a 55-year-old woman with a history of
taking estrogen for several years calls and requests a prescription renewal. The medication could be renewed without a chart
review if the caller was a long-time patient in the practice.
However, an actual chart review reveals that she has not had
a mammogram for three years because, although the mammograms had been ordered, the woman has cancelled every
appointment (Meiner & Steele, 1999). Because of the potential for danger when medication orders are communicated over
the telephone, orders must be written and cosigned according
to the hospital policy and procedure (Aiken & Catalano,
Another problem that can occur involves obtaining a telephone order for a do not resuscitate (DNR) order on a patient. If a controversy develops regarding the death of a patient
who has a DNR order, the nurse may be held liable if the physician states that he or she never gave such an order and did not
cosign the order (Aiken & Catalano, 1994). If a DNR order
must be obtained over the telephone, the nurse and another
witness on the telephone must sign and verify that they have
heard the DNR order given by the physician (Aiken &
Telephone orders should be written down immediately (see
Figure 1). Any telephone calls from other members of the
healthcare team also should be written in the record (Meiner
& Steele, 1999). Sometimes when taking telephone orders, the
connection is not always clear, which may cause words to fade
out or be misunderstood. When the nurse on the telephone
cannot clearly interpret the spoken word, he or she should repeat the name of the drug or dosage that was heard (Karch &
Karch, 1999). The nurse also should ask the prescriber to spell
the name of the drug and ask for the drugs indication (Karch
& Karch).

Nurses call log should contain

Date and time of the call
Physicians name and to to indicate telephone order
Verbal order, written word-for-word
Documentation that the nurse read back the order, to ensure
Documentation that the nurse transcribed it according to the
facilitys policy
Name of nurse who took the order.
Telephone advice log should contain
Date and time of the call
Name of caller or patient
Demographic information about caller or patient
Brief statement of illness history; signs and symptoms
Brief statement of advice given or protocol followed
Any warning given regarding time frame within which the
caller should be seen and warnings given regarding the severity of the illness.

Figure 1. Information Needed in Telephone Call Logs

and Advice Logs
Note. Based on information from Nurses Service Organization,
1999; Robinson et al., 1997.

Not only are nurses obtaining orders via telephone, but they
also are communicating medical advice that way. Briggs
(1997) described telephone triage as a systematic process that
screens the callers symptoms for urgency and advises the
caller when to seek medical attention based on the severity of
the problem described. This process involves the careful assessment, diagnosis, plan formation, intervention, and evaluation of the patient on the other end of the phone (Coleman,
1997). A documentation diary or log sheet is necessary in each
setting where telephone triage is practiced (Meiner & Steele,
1999). Nurses should be sure to follow hospital policies and
procedures with respect to telephone triage. Nurses who conduct telephone triage should avoid asking leading questions,
using medical jargon, stereotyping callers or problems, overor under-reacting, and second-guessing the caller (Wheeler,
1993). Nurses also should talk directly with the patient, not
just to family members, give the caller plenty of time to talk
about the problem, and adequately document the call.
Lawsuits involving telephone triage have focused on the
nurses failure to provide patients with adequate warnings regarding the dangers of not complying with the advice given
(Meiner & Steele, 1999). Not following hospital policies and
procedures for conducting telephone triage, especially documentation guidelines, can have serious legal implications for
the telephone triage nurse. For example, a nurse took a call
from a patient complaining of abdominal cramping and pain
(Buppert, 1999b). The nurse told the patient that the pain was
most likely gastroenteritis but to call back in two days if the
symptoms persisted. The patient called back in two days, complaining of the same abdominal pain. The nurse who took the
second call did not obtain the patients chart before talking
with the patient. The chart would have revealed that the patient
had an intrauterine device. This nurse also told the patient that
she most likely had gastroenteritis and to call next week if the
symptoms continued. In five days, the patient went to the hospital for an office visit and was diagnosed with severe pelvic
inflammatory disease. Later, the patient needed a hysterectomy as a result of the infection (Buppert, 1999b). This unfor-

ONF VOL 28, NO 4, 2001


tunate incident reveals how important knowing and adhering

to facility policies and procedures is, even ones that seem as
simple as having a patients chart when giving telephone advice.
Coleman (1997) suggested three ways to protect telephone
triage nurses from legal liability: correct use of protocols,
documentation of calls, and quality assurance and audit
checks. Appropriate and accurate documentation of calls increases the nurses ability to defend him- or herself in court
(Coleman). Good documentation aids the nurses memory and
offers proof of the advice that the nurse gave to the patient.
The chart should clearly indicate whether the documentation
is by inclusion or exclusion (Robinson, Anderson, &
Erpenbeck, 1997). Whenever possible, a nurse should quote
the patient (Gobis, 1997). If the telephone triage nurse deviated from the protocols at all, he or she should record the reasons for the deviation and record any discussions with the
physician or actions taken under the physicians direction
(Gobis). Telephone triage nurses who follow this advice will
provide better care for their patients and protect themselves
and their employer from legal liability.

A discussion of recent advances in technology is not complete without including what is now probably the fastest growing form of communication: electronic mail (e-mail). E-mail
provides direct evidence of a healthcare professionals conversation (Spielberg, 1998). The e-mail message is a medical
document and should be stored electronically or printed in
hard copy and placed in the patients record. E-mail is an efficient means of communication that actually decreases time
spent answering the patients questions by telephone or in person (Spielberg). E-mail also allows for a more detailed and
considered response to the patients question or concern than
a telephone call usually permits (Spielberg). From a liability
standpoint, healthcare professionals benefit from e-mail because it accurately documents the communication. In addition,
the patient may retain these communications. Just as standard
practice requires the retention of any written notes and any
information gathered related to patient history, complaints,
diagnosis, and treatment, e-mail messages should be included
in the patients permanent file (Spielberg).
Unfortunately, the introduction of e-mail systems into a
healthcare facility also requires taking several legal precautions, such as maintaining patient confidentiality, ensuring the
patients right to informed consent, maintaining the components of a medical record, and addressing customary usage and
practice standards, state licensing, and product endorsement
(Spielberg, 1998). E-mail security echoes other modern communication technologies, such as fax machines, because the
messages can be misdirected, printed, intercepted, rerouted, or
read by unintended recipients (Spielberg). An e-mail policy
should be in place to define the authorized use of the e-mail
system and define the penalties for improper use (Jurevic,
Because it is a fairly new technology within the medical
setting, e-mail requires further examination and evaluation to
develop practice guidelines for its reasonable use (Spielberg,
1998). But like other technologies that have made their way
into medical facilities, sufficient guidelines can and should be
developed, implemented, and followed by all healthcare providers who use electronic systems to preserve patient interests
and to avoid liability. Like a doctor's orders received by fax,

when guidelines are not available for a nurse who is receiving

an order via e-mail, the nurse should use whatever means necessary to confirm the order (Karch & Karch, 1999).

Computer Charting
Computer charting is fast becoming the norm in most hospitals. Electronic or computer documentation is used in varying degrees in many healthcare-delivery systems (Brent,
1997). The advantages of using electronic documentation over
handwritten charting include more accurate and timely charting, easy access to patient information, a more efficient
method of communicating, help with providing patient confidentiality, and more legible patient information (Aiken &
Catalano, 1994). Using computers for documentation of patient care also overcomes the lack of a standardized nursing
language. By having clinical languages built right into the
computer system or having templates that allow the addition
of language systems (Utz, 1998), nurses avoid using imprecise
terms when describing patient symptoms and treatment.
Computer documentation has been shown to be very beneficial to the healthcare systems that use this advanced technology. The University of Iowa Hospitals and Clinics implemented an online documentation system for patient care orders
that features order-generated task lists, default charting responses, computer-generated chart forms, and graphic data
displays (Prophet et al., 1998). The use of this online system
resulted in more positive user attitudes and satisfaction and
perceptions of less time completing other paperwork and more
time in patients rooms (Prophet et al.). In addition, the online
system can result in more accurate orders and overcome limitations of manual narrative and flow sheet charting by cueing
the user about what is necessary and appropriate to chart.
Computer programs are designed specifically for a particular type of patient care or healthcare setting. Some hospitals
have made use of computerized care plans. Oncology nurses
can use these plans for the treatment of a patients pain because the program includes information on different forms of
analgesia used by the pain service. The plan also allows nurses
to choose what information and guidance they require for their
patient (McArthur & Cunliffe, 1998).
Although computerized documentation has distinct advantages, it has some notable disadvantages. Some of these disadvantages include the reliance on electric outlets, limited number of terminals or access points, and lack of staff understanding computer technology (Meiner, 1999b). Most
importantly are the increased concerns about legal and ethical
issues that arise from this type of documentation. Much like
with fax machines and e-mail, nurses should be aware of confidentiality concerns that arise from the use of computers. The
storage of medical records on the computer and access to such
records are primary concerns (Aiken & Catalano, 1994). Electronic data cannot be locked in a file cabinet or storage room.
The computer-based record is only as confidential as the effectiveness of the electronic security system (Meiner, 1999b).
Managers should establish policies and procedures that address those concerns, including but not limited to internal and
external data sharing, monitoring and reporting of data, periodic review of the data entered into the electronic system, and
methods for the patient to provide consent for the use and release of the stored information (Brent, 1997).
Nurses should follow their facilitys procedures for computer-based documentation, such as disposing printouts and



transferring documents. Nurses must remember that any entry

made and stored in the computer-based record is considered a
permanent part of the record and may not be deleted (Meiner,
1999b). After the entry has been stored, nurses must follow the
proper procedures for correcting errors (Meiner, 1999b). The
American Health Information Management Association recommends the following safeguards (NSO, 1999).
Double check the information entered.
Note whether a physicians order is written or verbal.
Passwords should not be told to anyone and should be
changed on a regular basis.
Patient information should not be left displayed on the computer screen.
The computer should be logged off when not in use.
Printouts should be retrieved immediately.
Regardless of whether the nurse is using the fax machine,
telephone, e-mail, or modem, security of patient information
is extremely important. Any information that is transferred
should be designated confidential, and instructions for
proper disposal should be included in the transmission
(Meiner, 1999b). In addition, release forms are required when
discussing, copying, mailing, faxing, or destroying any part of
a patients record (Meiner & Steele, 1999). Nurses who follow
these points in electronic documentation guidelines can protect
a patients right of privacy and confidentiality of the stored information and protect the legal interests of those using the system correctly.

Documentation is an important part of any nurses practice,
regardless of the healthcare setting. Nurses can be liable for
inadequate documentation of a patients record, like all other
healthcare professionals. The patients expectations of privacy
and confidentiality are very important issues in the healthcare
setting, especially with the ever-increasing reliance on advanced forms of technology. Nurses must follow their
facilitys guidelines for documentation practices in every aspect of care that they provide, whether in obtaining informed
consent electronically, filling out the patient chart, or taking
orders over the telephone. Nurses should insist on the highest
level of care for their patients, which means proper documentation of each patients record. Nurses must be knowledgeable
about the risk factors associated with the emerging electronic
technologies related to nursing documentation and confidentiality expectations and implement risk-reduction practices
when using these new methods of communication. Nurses who
follow exact standards for documentation, regardless of the
technology used, will be providing a complete and accurate
account of patient care, thereby reducing the chance that questions will arise regarding their documentation.

Author Contact: with copy to editor at rose_mary

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