In nursing practice, there should be no room for errors. Everything must be well accounted for and documented in order to provide the necessary treatment and care for patients. If nursing documentation isn’t done the right way, the nurse can be in real trouble. All the nurses are well aware of the standard for nursing practice, which require every one of them to document appropriate and accurate reports of significant observations including conclusions obtained from those observations.
A truthful and precise nursing documentation can help nurses defend themselves in the case of malpractice lawsuit, not to mention keeping them of court or possible imprisonment. There will never be any lawsuit due to malpractice if only proper nursing documentation is being followed. Besides, it is not something that nurses learn only during the first day of their job. They were trained to do it while they were still studying. They will never become nurses in the first place had they not learned how to chart everything affecting patient’s care, will they?
In nursing documentation, there are certain things that nurses can do and cannot do in order for them to avoid mistakes. Again, there’s no room for mistakes when it comes to nursing practice. Let us first take a look at the things nurses can do. Before doing any nursing documentation, make sure you have the right chart. It may sound very basic, but it is important, in case there’s an error, the investigation starts here. Also, make your writing readable, because you won’t be the only one to read the documentation.
Make sure that your documentation reflects the nursing process and your professional skills. The times when you give medications, the administration route, and the patients’ responses should be correctly charted. Any precautions or preventive measure used must be recorded, as well as phone calls to a physician with exact time message and response. If there’s an important point you remember after the completion of nursing documentation, record the information with a note that it’s a late entry.
Now, let’s go to the things nurses cannot do. In a nursing documentation, bear in mind that you cannot change or modify any patient’s record as it is a criminal offense, but of course nurses knew this already. You cannot document what other people said or observed, unless the information is serious and important. You cannot and should not document care ahead of time as something may happen and you may not be able to five the care you have documented beforehand. Besides, charting care that wasn’t done is fraud, so think about it!
Be specific on your descriptions, you cannot just describe something vaguely, like large amount or bed soaked. In order to uphold accurate nursing documentation, you cannot use abbreviations, or shorthand that are not widely accepted or better yet, don’t use them at all. That way, you can provide nursing documentation that is legible for anyone to read.
As you may have noticed, nursing documentation is a serious procedure that should be done the right way without any errors at all. The reminder is worth repeating, considering what you may end up with in case something goes wrong in you documentation. So, be very careful!
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