Our very own Kaitey Morgan, Director of Quality and Standards, wrote an insightful post for The WeInfuse Blog regarding the importance of thorough clinical documentation and best practices. Read the following excerpt for a sneak peek, and then follow the link below to read the full post on the WeInfuse site.
As the saying goes: if it wasn’t documented, it wasn’t done. This mantra is instilled in nurses throughout our education and training, and for good reason. Clear, accurate, timely documentation in the medical record, whether electronic or—gasp!—paper, is an essential component of patient care in all settings, as it provides a lasting snapshot of each encounter.
In a field as unique as infusion therapy, there are certain aspects of documentation that warrant special consideration. The billing aspect of infusion documentation gets a lot of attention; after all, if it wasn’t documented, it wasn’t done, and you won’t be getting paid for it. But what about conversations had in passing, or the quick “doorway assessments” that often don’t make it into the chart?