Tips for Keeping Great Documentation of Nursing Career

Nursing is not a profession just about skills, it is also about people's vocational needs.Given their role as caregivers, it is obvious that these professionals should be interested in their patients and what they have to say about the way they feel.

Some time ago the following question was asked to 1,200 registered nurses: "What do you consider most important in your work as a nurse?” More than 95% responded that the main focus of the profession was to provide quality care.

Needless to say, providing care continuously can create great strain on the professional who works ten hours a day or more. What prompted these unselfish caretakers to go into nursing? In addition to providing satisfactions, nursing presents many challenges. There is no place for mistakes. Whether medication is given, blood is drawn, an intravenous cannula is inserted, or the patient is simply moved, care must be given. No oversight can be made, especially in countries where courts are immediately appealed to. Even so, nurses sometimes find themselves in difficult situations. For example, nurses in situation of thinking a doctor has prescribed the wrong medication, what can she do? Question the doctor's decision? Doing so requires courage and diplomacy, and involves some risk. Unfortunately, some practitioners do not readily accept the suggestions of those who they consider subordinates.

However, taking into account the kind of situations nurses can end up being involved in, it is quite important to take documentation very seriously. Documenting patient care is usually the first point of contact nurses have with patients, and it has to be carried out strictly since it is critically important for both types of reasons: legal and practical. Among the benefits that proper nursing documentation can provide it is possible to highlight it helps prevent medical errors, it can be extremely helpful for malpractice lawsuits and it is an important to promote top quality patient care.

For all the aforementioned reasons and noting that nursing documentation plays a vital part in delivering patient care that is up to the standards, it is important to know how to carry it out properly. This article is a list of tips that can be very helpful for proper nursing documentation. People should always keep in mind that documentation needs to be precise and as accurate as possible, this is a piece of paper that needs to serve as reliable information about the patient:

Documentation needs to be accurate

All the information written down by nurses needs to be accurate since any kind of inaccurate documentation can lead to harming patients as a result of misleading practitioners and other nurses’ decisions.

It is important to avoid late entries

As late entries can be the source of many inaccuracies, the best decision is to avoid them at all costs. If something happens after the fact stated in the original document, the process to write down a late entry should be done according to what is established in the employer’s late entry policy. In most cases, late entries need to be clearly marked, it is the most recommendable thing to do.

Get familiar abbreviations and use them

In most healthcare settings, as it happens in many other fields of professional practices, abbreviations are part of day to day written and systematized language. Nurses are usually required to be aware about these abbreviations because they save time and can be defined as simplified terms that everyone using said document will understand.

It is recommendable to use abbreviations that are part of the standard used by the employer, avoiding colloquial abbreviations that may confuse other people in power of the document.

Noting symptoms and treatments for them is essential

The main reason for a patient to go to a healthcare facility (other than routine checking) is because they feel or notice something about their organism that is not right; for this reason, proper documentation of symptoms and the treatment that has been prescribed are vital information that needs to be part of nursing documents.

Always prioritize legibility

Nursing documentation is not a personal notation, and it is going to be read by others. Other people need to be able to read said documentation easily in order to avoid misunderstanding that can lead to improper decisions.

Only facts can be taken into account for nursing documentation

It is not a common mistake since patient-care professionals are aware of it in most cases, but it is still important to note that nursing documentation should only contain facts and reliable pieces of information and it cannot be based on opinions or hear-says. Whenever it is required to indicate an opinion or something that cannot be considered a fact, nurses should use quotation marks.

Always document all types of physician consultations

All types of consultations done to the physician during patient care need to be noted down as specifically as possible including names, exact times, responses and all resulting actions from said consultations.

Use ink

Nursing documents are considered legal documents that can be used in a lawsuit. They are also stored and used long time after they are written down. In order to prevent its erasing due to the passage of time, use only blue or black ink.

These tips guarantee proper nursing documentation, following them is the best way to carry out accurate notation of relevant information regarding all aspects and eventualities occurred during patient care.

Improper documentation can lead to several errors that can affect treatment of an illness in a big way. The following errors are some examples of what proper documentation can avoid:

• Blank spaces on treatment charts: blank charts reveal lack of important and necessary information, they can create confusion. No one but the nurse that was in power of the chart is able to know if the treatment was administered or not. Blank spaces in charts can have severe legal consequences since all sues carried out by patients can be way stronger if there is a blank space on a treatment chart. Treatment charts are the only way to prove a treatment was correctly administered.
• Omitting allergies or medication: this is probably the most serious error that can be result of poor nursing documentation. Doctors need to know if patients are allergic to something in order to prescribe the right treatment, otherwise they can end up prescribing something that harms the patient and can even cause death. It is also required to note down the secondary effects granted by prescribed medication. Proper documentation of medication includes dosages, permissions required and type of medication administered.
• Unclear orders: documentation is also valid to serve as base to question orders. If the nurse receives an order that they do not quite understand, it is always a good idea to ask for clarification and use documentation as a way to back up said questions. Patient care cannot be carried out according to suppositions and guessing, it requires facts and physicians can also mistake, nursing documentation can support or reduce credibility of a decision.