Documentation for the Correctional Nurse

3.0 Continuing Education Hours

Documentation is one of the most critical skills nurses perform, regardless of the setting in which they practice.  Accurate, detailed charting provides a clinical picture of the patient and a chronological history of their health care.  Nursing documentation enables effective continuity of care for the patient.  It also provides legal protection for the nurse  and their employer.  Nursing documentation provides important information for Continuous Quality Improvement projects and audits, and provides information about the care given at the facility to such accrediting bodies as the National Commission on Correctional Health Care and the American Correctional Association.  Always remember that what is charted today may be read in the future by many people, including other team members who care for the patient; accreditation, certification, and licensing organizations; performance improvement committee members; and lawyers and judges if the inmate’s medical record becomes part of a legal action.

While there are many different methods of nursing documentation that have been developed, the two most commonly used in correctional environments include the Narrative Note and the SOAP note.  In this class, the Narrative and SOAP formats will be reviewed, including the advantages and disadvantages of each.  Electronic Medical Records will be discussed, as we are seeing them more and more in the correctional environment.  The risk liability and legal ramifications of nursing documentation, especially as it applies to the correctional setting, will also be discussed.