Talking to a fellow nurse today discussing how much documentation nurses must do to justify that standards of practice are met. The mantra we are taught right from nursing school is “If you didn’t document it ; it wasn’t done” We have been led to believe this in our educational, tracks, our jobs and governing organizations like CMS. Even our own nursing organizations have us believing that we need to document every response to “everything” to prove that we are practicing our craft appropriately. A lot of nurses feel they are documenting more than providing care. Some areas of nursing are not experiencing this pressure. How about you? Where do you stand on the issue? Is there too much documentation being done? Is it all necessary?
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