Page 7 - INTRODUCTION OF NURSING 1.4 The Nursing Process (PART 3)
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Introduction
➢By concentrating on the principles of documentation your documentation will reflect
the quality care you provide and reduce the risks of a lawsuit.
➢One of the cardinal principles of legally defensible documentation is adherence to
organizational policy and procedures (P&P), standards of care, guidelines,
competencies, and any other organizational document that guides the care of patients.
➢The reasons for deviation from these documents must be clearly supported in the
medical record.
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