Posts Tagged ‘Nursing’

If it wasn’t Documented, It wasn’t done!

Sunday, October 11th, 2009

How many times have we all heard, “If it wasn’t documented, it wasn’t done”? Far too often, we’re sure. Seriously, we as clinicians should take note of our documentation practices. Below is a short clip (Part 1 of 4) in which WCEI’s own Cindy Broadus RN, presented to the attendees at the Wild On Wounds Conference in Las Vegas NV in September. Her session was titled “If It Wasn’t Documented, It Wasn’t Done! Documentation Woes”.

Here was the description of the session: The medical record is considered to be the most reliable source for determining what happened. It is a legal document, yet not always treated as such. With litigation lurking around the corner for every health care professional, we, as Wound Care Certified professionals, need to make sure our documentation is complete, concise and correct. Come on it and let’s talk about correct terms, techniques, and steps it will take to keep you out of trouble.

Cindy always knocks it out of the park! Great job Cindy!