Legal/Regulatory Paper: student will describe one legal/regulatory issue and clarify how this issues is relevant to their nursing practice they will identify 2 ways in which they can reduce their risk for this legal issueBecause of nursing documentation issue my hospital is having with copy and pasting issues in the EMR. I choose to use Legal regulatory issue with documentation. Im an ICU nurse educator studying to be a ICU CNS and I work closely on documentation in my Hosptial. I have looked up articles which can be used however you are free to look up some of you own if you find any better.Documentation is vital to nursing legally (not documented, it wasnt not done) nurses can be charged with negligence and malpractice. At my Hosptial we do have a copy and paste feature on the notes portion which allows anyone to copy & paste another person note and sign it without locking.The plan is to remove this feature however the issues Im having in the ICU is so many notes and documentation with assessments every 4hrs. We want to lock this feature to copy and paste only your own and make wound care another note or flow sheets. We have already lock these flow sheets for drains and lines which only the nurse who documents can copy & paste their own note. We also have notes we dont use nor need in the ICU but are mandatory for the hospital wards. We just did a JACHO and we do have issues with documentation.I want to decrease double documentation, amount of documentation, and I love technology with the of tablets which of course we dont have but computers are hard to find and they remain locked with a card you can only access if you have the time to sit and log in. I will not have this issues with I had tablet at the bedside not a computer. I only document what is needed for care but remain the standards of nursing.
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