International Nurses Association

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 r equire the most extensive documentation, it's actually an exten...