- Be Accurate. Write down information accurately in real-time. …
- Avoid Late Entries. …
- Prioritize Legibility. …
- Use the Right Tools. …
- Follow Policy on Abbreviations. …
- Document Physician Consultations. …
- Chart the Symptom and the Treatment. …
- Avoid Opinions and Hearsay.
The nursing care we provide to our patients includes keeping good records, so this couldn’t be more incorrect. Remembering everything you did and everything that occurred during a shift is incredibly difficult. Our handover to the following team of nurses won’t be complete without complete and accurate nursing records for each patient. Needless to say, this can affect the wellbeing of patients.
In fact, the standard of care we provide to our patients can be reflected in the quality of our record keeping. Careful, organized, and accurate patient records are the signs of a compassionate and responsible nurse, whereas poorly written records can raise questions about the caliber of a nurse’s work.
Another important consideration is the legal significance of nursing records. Your nursing records are the only evidence that you have upheld your duty of care to the patient if the patient files a complaint. In many nations, it is legal to assume that care or treatment owed to a patient has not occurred if it is not documented. Even if you are certain that you provided the proper care, poor record keeping could lead to a finding of negligence, which could result in you losing your license to practice.
In summary, the patient’s nursing record gives an accurate account of the care and treatment provided and enables effective communication between you and your team members who work in eye care. Maintaining accurate nursing records also enables us to recognize emerging issues and the steps taken to address them.
NURSING DOCUMENTATION TIPS (2018)
Why is accuracy important in nursing documentation?
Because doctors, nurses, and other healthcare professionals rely on the details in a patient’s chart to carry out their duties, which may include creating treatment plans, giving medications, or consulting with other specialists, accurate nursing documentation is crucial. The patient’s vital signs, their level of pain, any escalation of their symptoms, and any emergencies they encountered during their stay in the hospital are all typically recorded in the patient’s chart by nurses.
Additionally, documentation enables managers and hospitals to confirm that a nurse followed protocols when administering medications and treatments. To guarantee that patients receive the best care possible, your employer’s protocols may include how you complete your documentation. Think about the potential impact your documentation may have on a patient’s development and the additional care they receive from other medical personnel.
10 tips for good nursing documentation practices
You can maintain good nursing documentation practices by using the following advice:
1. Take notes in real time
It can be difficult to recall every detail of a day with any one patient due to the variety of tasks you may be in charge of and the number of patients you may be responsible for caring for. You must make sure to update and complete your patients’ charts throughout the day to avoid forgetting to record a crucial detail that could aid another medical professional in understanding a patient’s condition.
Consider including the precise time of your visit with the patient in your notes. These specifics can let a doctor or nurse know when a patient needs medication or if their symptoms are getting worse because patient care is time-sensitive. Additionally, it’s critical to make sure your patient receives care according to schedule and to facilitate a smooth transition to the following nursing shift.
2. Take HIPPA-compliant notes
Healthcare professionals can use the Health Insurance Portability and Accountability Act (HIPPA) as a guide to protect the privacy of their patients. To maintain the security of patient files, statuses, treatments, and other information, nurses and others working in the healthcare industry must adhere to certain HIPPA requirements. It’s crucial to be able to take notes without jeopardizing a patient’s privacy if you manage several patients and must visit some of them before entering information into your facility’s secure computer system.
Some nurses will fold a piece of paper in quarters, write on each quarter, and identify the patient by room number until they can get to their official chart in order to maintain patient anonymity when making rounds or managing multiple patients at once.
3. Write legibly
In nursing school, nurses typically learn early on that patient charts are official documents. Consider taking handwritten notes only in blue or black ink and noting any necessary corrections rather than attempting to erase errors to ensure that you are treating charts properly. It’s also crucial to write clearly so that anyone reading your notes can understand your communication and goal.
4. Note allergies and special waivers
Take note of all the sensitivities and allergies that patients disclose to you when you ask about their allergies. This step in the documentation process is crucial because some medications may contain ingredients that resemble allergens and may negatively impact a patient if a nurse fails to accurately document the allergy. Consider including notes on details such as:
Some patients will also decline specific treatments, like blood transfusions, due to their personal or religious convictions. It’s crucial to record the patient’s wishes in their medical record so that other healthcare providers can ensure that the patient’s wishes are respected and prevent any potential legal issues.
5. Document the symptom and the treatment
Note both the patients symptoms and the treatment you administered. Explore the parameters of normal for your patient’s condition and the “within defined limits” range if your institution records exceptions to typical symptom progression so you can thoroughly and accurately record any abnormal findings. It’s also crucial to gauge a patient’s level of discomfort and record their response. Although each patient’s pain threshold varies and pain is relative, pain can be the body’s way of signaling that something is wrong. Intense or persistent pain can assist a medical professional in diagnosing and treating a patient.
6. Document physician consultations
Consider how crucial it is to document every interaction between a doctor or charge nurse and the patient. Include the patient’s response, the time of the interaction, the doctor’s or nurse’s name and title, the interaction’s date, the healthcare provider’s remarks, and any actions the doctor suggests or prescribes. Having a complete record of all communications can help other caregivers for the patient act in accordance with your recorded details.
7. Complete the entire chart
A complete chart is essential to providing high-quality patient care, as any blank spaces that should inform the care team of crucial information can compromise the quality of the patient’s care. If you fail to note when you gave a patient their medication or that they received a particular treatment for their condition, a blank space may appear in their chart. Any blanks in a chart can also prompt a different member of the care team to spend time investigating or questioning the treatment the patient received from the prior nurse.
8. Use the correct abbreviations
Abbreviations are frequently used in the healthcare industry because they make it easier for medical professionals to quickly record patient details. Make sure that any acronyms you use are appropriate for your hospital, practice, or medical facility. Use abbreviations that anyone reading the chart can understand because they facilitate communication.
9. Use the tools available to you
Automated chart solutions are becoming commonplace for many healthcare organizations. Utilize digital technology, such as computer charting, to the fullest extent if yours has it. Digital tools, like scanning wristbands each time you administer medication, can help with seamless real-time note-taking and ensure that records are accurate.
10. Ask a colleague to review your documentation
Ask a dependable colleague to review your work if you’re new to nursing or documenting for your company, or even if you have a particularly detailed case and want to make sure your documentation is complete and accurate. This could be a charge nurse, a nurse who has worked at the organization longer than you have, or a doctor you speak with frequently. They can probably give you feedback that will aid others in understanding your charting and assist you in learning industry best practices that you can apply to your subsequent patient.
What is good nursing documentation?
Assessment, planning, implementation, and evaluation of care should be included in the nursing record. Ensure the record begins with an identification sheet. Name, age, address, next of kin, caregiver, and other personal information about the patient are included in this. Every continuation sheet needs to include the patient’s full name.
What are the do’s and don’ts of documentation?
The documentation needs to be concise, legible, and clear. Accurate information must be provided regarding the steps taken, evaluations, treatment outcomes, complications, risks, reassessment procedures used during treatments, and changes made to the treatment.