Abstract
You wake up in a cold sweat after dreaming that you're the defendant in a medical malpractice case. The plaintiff's lawyer was about to point out the flaws and gaps in your documentation. Thankful it was only a dream, you vow to make sure your charting is up to snuff.
No matter how skilled a nurse you are, poor nursing documentation will undermine your credibility if you're ever involved in a lawsuit. Read this article for practical guidelines that will not only improve patient care, but also help shield you from legal fallout if something goes wrong despite your best efforts.