In addition, inappropriately prescribing opioids, resulting in their misuse and abuse, has led to many changes, including new safety and quality recommendations that must be considered. As prescribers, it is critical that nurse practitioners understand not only federal but state requirements for prescribing all controlled substances. Department of Health and Human Services (HHS), all have a role in determining the scheduling of prescription medications. The Drug Enforcement Agency (DEA), along with the Food and Drug Administration (FDA) and the U.S. Good documentation can support workflow, improve efficiency, and increase productivity.Īppropriate prescribing practices are critical for all medications, but drugs that are considered controlled substances require additional attention. Inadequate or poor documentation may not tell the whole story of care or patient outcomes and could result in allegations of negligence, fraud, abuse, or malpractice. Documentation done using best practices accurately reflects the patient’s true clinical situation as well as trends toward recovery or complications. Nurses commonly experience conflict between time spent caring for patients and time needed to accurately record care provided and a patient’s response to treatment. Additionally, incomplete documentation can negatively affect communication and coordination of services between healthcare providers, which can in turn affect patient care. Incomplete, inadequate, or inaccurate documentation can adversely affect reimbursement and accreditation and have legal consequences that may expose the nurse to liability. This course emphasizes compliance with documentation for nurse accountability and performance evaluation. Requirements for documentation in terms of regulatory, accreditation, and legal requirements are continually evolving, especially with the advent of electronic medical records. This ensures that nurses account for the care that is provided and the resulting patient outcomes. Nursing documentation is an integral part of clinical nursing care. *Excludes Exam and Certification Preparation courses
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