Defensive Documentation For Long Term Care

This concise guide shows you how to protect your facility by explaining how to fill out the various pieces of the medical record in a manner that makes it least vulnerable should it be used as evidence in a lawsuit. It gives charting examples of “good” and “bad” documentation and explains how to avoid common documentation pitfalls. It also outlines several different techniques nurses and other caretakers can use to document resident care in a way that can be defended in court.