06-u5-t-1-2 Assignment: Documentation and Regulatory Compliance

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Documentation and Regulatory Compliance

The advanced practice nurse should understand the legal framework for documentation in the medical record. The federal and state governments afford patients protection from disclosure of health care information. The nurse must know how to document when he or she challenges a physician’s order to protect him or herself and maintain the safety of the patient. Incident reporting of an adverse patient occurrence must state objective findings and should not contain opinions or subjective information. Blame should not be included in an incident report. Confidential information that is mailed or shared with the institution’s attorney may be considered attorney client privilege. Documents that are attorney client privilege are not discoverable by the suing party.