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REPORT DOCUMENTATION PAGE Ntis  Form

REPORT DOCUMENTATION PAGE Ntis Form

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chapter 19 documenting and reporting the patient record is a compilation of patients health information each healthcare institute or facility has policies that specify the nurse's documentation responsibilities the joint commission specifies that nursing care data related to patient assessments nursing diagnosis or patient needs nursing interventions and patient outcomes are permanently integrated into the record the patient record is the only permanent legal document that details the nurse's interactions with the patient it is the nurse's best defense if a patient or patient surrogate alleges nursing negligence unfortunately there are crucial emissions in the nursing documentation along with meaningless repetitious or inaccurate entries although these entries might go undetected and have no effect on the patient they might also seriously affect the care of the patient and undermine nursing's credibility as a professional discipline and cause legal probl

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