Patient Documentation Advice that all Nurse Should Consider
Advice for Documenting Nursing Work
A nurse is only deemed as valuable as her performance. Documentation means everything in hospital or clinical procedure. While patient safety is first, adherence to documentation rules are a close second. You will avoid incurring the wrath of management by always remembering these advices for documenting medical work.
Always be sure when it comes to medicine
Medication errors happen more than rarely, much to the expense of hospital management. Not only is this costly, but it’s downright dangerous to patients who have been prescribed specific brands and dosages. Proper medical documentation is essential, and hospitals, doctors and nurses can be sued for incurring damages to patients because of these errors. You must be absolutely sure the right drugs are administered as directed. The most important documentation steps are: the purpose of the pills, potential adverse reactions, proper dosage based on the condition, and directions for administering.
Watch for other types of instructional errors
While not all document errors are lethal, they are extremely inconvenient and can slow efficiency down. It’s not merely the right or wrong medication, but nurses must also document when the patient is given medication, and when it will be safe to give him or her another dose. Transcription errors can be disastrous, not only because of poor proofreading, but also because of illegible penmanship and abbreviations. In fact, nurses are told not to use abbreviations, especially when dealing with medications that have similar names.
Always report on patient progress
You are a patient’s advocate, and practically their only advocate, since the doctor is making decisions based on your information and the patient’s words. You must report patient deterioration or any other changes, so a doctor can use this information for diagnoses. You are in charge of continually evaluating their condition, attitude and any other symptoms. Remember, you must be one step ahead of patients; not merely taking notes based on their description, but also noticing their body language.
Follow orders closely when transferring patients
In other jobs, we often transfer customers to other representatives and never give them another thought. You can’t do this in a hospital or clinic setting. You must always communicate between all the doctors, nurses, caregivers, family members and patients you come into contact with. Even if someone is transferred, you must provide all documented information, making sure the other nurse understands the condition. Always document how the patient is responding, changes made to his or her plan and so forth.
Always be aware of proper procedure
No guessing. Follow your hospital’s documentation procedures and adhere to all policies. This not only shows respect for the facility, but also protects you from termination, company lawsuits, individual lawsuits, and all other sorts of bad news.
Date, sign and time every entry
Remember that much of this information would be meaningless unless you can also tell the doctor the precise time and date. Sign every entry so the doctor and other nurses can keep track of the latest progress reports.
Always tell the truth
Sometimes patients will refuse treatment or not take his or her medication. This must be documented, including any other contacts involved in the situation. In lawsuits, doctor and nurse documentation are almost always reviewed in evidence.
Accuracy of statement, proper timing and marking, and legible notes are all equally important. This effective organization will help patients, ensure quality care, protect the hospital and its workers from violating state law or civil lawsuits, and will also help validate reimbursement claims from the insurance company. These advice will keep you legally safe and in happy spirits.
