Best Practices in Nursing Documentation

Healthcare Training Resource
May 17, 2013 — 2,271 views  
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Robust and accurate nursing documentation is an essential part of keeping medical practices away from litigation and lawsuits. With accurate documentation, patients can be more easily treated with the medications and procedures that have been noted to work best for their unique needs. For those who are new to the profession, or those who merely require a brief review, there are several key practices to be followed universally when meeting with every patient.

A Look at the Basic Best Practices for Nursing Documentation

The best place to get started when learning about excellent nursing documentation practices is simply to start with the basics. From legible handwriting to basic notations, nurses should be sure to adhere to a few best practices when noting a patient's condition, chronology, and even medications.

1. Establish a firm chronology of symptoms, treatments, and side effects, noting accurate dates and times whenever possible. Nurses should sign and note their position after every single event in the chronology, rather than waiting until the end of a page or the end of the chronology itself.

2. Legibility is absolutely essential, as the record will often be shared among numerous nurses and doctors during a patient's time with a given health care provider. For this reason, abbreviations or nonstandard notations should also be avoided in an effort to eliminate confusion. Slang, too, is generally not acceptable in nursing documentation.

3. Do not notate information twice, three times, or even more. It is accepted within the profession to simply note that a care provider should refer to previous notes for duplicate symptoms or other information.

4. It is not acceptable to accuse a patient's prior nurse, physician, or medical care provider, of any malpractice or improper treatment. The job of documentation is to note conditions, not point fingers.

5. Fraud and falsified records will lead to lawsuits and extensive litigation, so this nefarious practice should be avoided. If a given piece of information cannot be obtained, note that fact and move on.

Medications: Another Key Area for Proper Documentation

Some medications might produce serious side effects in some patients, while others will largely be reported as ineffective at treating a given medical condition. When noting medication use and effects, a number of best practices must be followed.

1. Patients should be asked about their experience with a medication's effects, and those effects should be noted chronologically and in simple language.

2. If a medication is determined to be ineffective, this should be noted and a revised prescription should be issued by the physician if such action is deemed necessary.

3. If medications are withheld from the patient for any reason during their time in a medical care facility, the held medication, its dosage, and the reason for withholding it from the patient should be noted in chronological order and in very simple language.

Best Practices Help to Avoid the Worst Consequences

In medical malpractice lawsuits, there are two key terms used against care providers by patients and their attorneys. The first is "failure to report," which indicates that a given condition, side effect, or treatment, was simply not included in the file. The second term is negligence, accusing care providers of simply not being competent in their use of a treatment. Avoid these charges, and the costly associated litigation, by strictly adhering to all nursing documentation best practices in every area of treatment and diagnosis.

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