The Best Practices in Nursing Documentation

Healthcare Training Resource
August 15, 2012 — 1,400 views  
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Documentation is mandatory for nurses, as the medical records they produce are considered legal materials. These professionals should maintain accurate information, including a chronology of events that features the date, time and nurse's full signature after services were provided.

While nursing documentation might seem like a time-consuming process, there are several practices these professionals can follow to provide legal proof of patient care.

Use computerized entries

Handwritten records might seem more authentic, but problems could quickly arise if they are used. For example, the records could appear illegible, which might cause safety issues.

When you manually enter records into a computer database, this information can be easily accessed at any time. Nurses can simply use a password-protected login to add details about patient care, and may print these documents if necessary. Meanwhile, these clean, crisp records will also be easier to read.

Avoid shorthand

You might use your own abbreviations when taking notes, but it's rare that your colleagues will understand what you might mean from certain phrases or words. While it might seem inefficient to write terms out, you should do so in various situations.

For instance, you might abbreviate euphemisms or slang to help you remember a specific diagnosis. This might benefit you, as you'll be able to save time documenting the care you provided a patient.

However, it's worthwhile to take an outsider's perspective when examining why you should not use shorthand. This practice essentially limits co-workers' immediate access to materials, as they will either need to contact you to find out what you are referring to or make guesses based on the rest of your notes. This could result in severe ramifications that could lead to improper patient treatment and legal penalties.

Rather than face possible risks, invest time now to avoid time-consuming issues for yourself and your colleagues down the line.

Include details

Be as specific as possible when documenting patient assistance, as this could prove valuable with future treatments. Make sure you indicate any symptoms the patient experiences and medications he or she may take. Additionally, you'll want to track the effect of any care provided, as this will allow you to see the effectiveness of your support.

The notes you take could have a significant impact on a patient's health. Dedicate the resources necessary to make sure this person receives the assistance he or she deserves. 

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