Notes are
critical to patient care. They must be
detailed and accurate, yet not go on and on so that the reader gets
uninterested. Notes should always be
clear and precise, and it's a good idea to go back and read them after you
entered them. Read them as if you did
not write them, and as if you are reading them from someone else.
Documenting
Documentation
is vital in a nursing role. Lack of
documentation is a serious mistake, and is not tolerated by medical
facilities. Many nurses put the
emphasis on patient care, which is great, however documentation is part of that
patient care. Nurses are busy, everyone
knows and understands that, sometimes there is not a moment to breath, and it's
hard to find time to document. The
document portion of the job should be considered as important as medication
administration, it must be done. Often
the busiest times are the times that require the most
extensive documentation, it's actually an extension of the busy time in many
cases. Schedule your day so that you
allow for adequate time to document, even if it means you stay beyond your
shift ending. If you feel you need
assistance in arranging a time to document, speak with your supervisor and ask
for help.
Prioritize
Documentation
Critical
lab reports require immediate attention. Most facilities require them to be reported to the head nurse, followed
by the patient's physician. Other
documentation that would be considered critical would be-
- The
patient is very confused and unaware of surroundings, when this is not normally
the case.
- A
patient falls, which requires an incident report, but should also be documented
in your notes
- A patient talks of suicide or there are
indications they could be suicidal.
Never
use generic statements, such as the patient's doctor called. Why did they call, what did they say, did
they leave orders? Be complete when
providing this information.
Note
Examples
Unacceptable
Note
-Mr. Blank
was irritable today and got sick. Doctor
called.
-Blank was
throwing up the doctor said give medication
-Mrs. Blank
asked for extra pain medication at 12
-Blank was
very upset, but later calmed down
Acceptable
Note
-Mr. Blank
was upset earlier in the day. At 1:00 pm
he regurgitated a sizable amount. Doctor
was called and gave an order for an anti-nausea medication, see medication
chart for time administered. Mr. Blank
felt better after 4, and drank ginger ale with no problem.
-Blank was
vomiting, 3 times before noon. Doctor
was doing rounds at the time and added a medication to help with the vomiting. He felt better in the afternoon and ate some
soup and toast.
-Mrs. Blank
asked for extra pain medication at 12:00 pm. I reminded her that she had already received medication at 10, and that
no more could be administered until 2:00 pm. She was accepting of that explanation, and soon after fell asleep.
-Blank was
very upset around 2 pm, saying that he wanted to leave the hospital. I talked with him to find out why, and he
indicated he was tired of being in bed. Blank was helped up and took a walk around the floor. Afterwards he was calm and said no more about
leaving.
There is a
huge difference between a good and complete Note, and a note that is done in a
hurry, and lacks substance. Electronic
records have improved every area of charting and documenting. You no longer have to hand write and attempt
to read and writing. Typing is still not
100% perfect, there is human error on a keyboard, and don't forget spell check,
which can take a slightly misspelled word and change it completely.
Do’s and
Don’ts of Note’s
Never-
- Document
in advance. You may plan to do
something, or anticipate an action, but if it has not happened, don't document
it.
- Late
entries should not be made without a supervisor's approval. If you forgot to write a note at one o'clock
/don't go back and enter it after later notes unless a supervisor authorizes
it.
- Corrections
after the note is entered should be handled with extreme caution. Never delete, simply highlight and add the
correction per hospital policy.
Always-
- Document in a timely manner, preferably
right after seeing your patient.
- Make
a notation at the accurate time if you failed to mention something in your note. Highlight that it is an addendum to the 12 pm
note, for example.
- Always make a special area if a
correction to a note is needed.
- Always put your identification to the
note, and make sure the day and time are noted.
Complete
and accurate notes will make your job easier, those around you will benefit,
physicians will greatly benefit, and the patient will receive the best care
possible.
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