Proper Documentation in Nursing: Why It’s Important

September 25, 2013 in Nursing TIps

Nurses are known for being experts when it comes to multitasking. However, the real challenge when it comes to doing well in nursing jobs is to perform each tasks to the best of one’s ability. Getting a lot done but doing sub par isn’t good enough to excel in the world of nursing and healthcare in general. Professional nurses understand that they must excel in all aspects of their career, including proper documentation.

Of the many responsibilities nurses have, taking down vital patient information is a crucial part of the daily routine. Although this might not seem like a very big deal, failing to properly document data could result in a number of errors that could potentially put a patient’s health and even their life at risk.

Documentation can be tedious at times but when it is done right the first time around–and every time after that–it will make a nurse’s shift much smoother. Nursing students are taught about this subject in school but only when presented with the task in a real hospital or clinic can new nurses really grasp the importance of mastering the technique of taking down proper notes and documentation.

Communication is Key

Nurses can’t document a patient’s information and medical history without talking to them. Communication is the first important step in the documentation process. This is where new nurses can really shine because the more comfortable the patient is with them, the more forthcoming they’ll be with their information. Remember: there is no such thing as too much information! Even the simplest statement could end up becoming very important when determining a diagnosis or treatment.

Instead of writing everything in your own words, write down exactly what the patient has told you. Documenting their words verbatim is often the best way for nurses and the physician to put themselves in the patient’s shoes to find out what is ailing them. This is especially crucial when it comes to descriptions of symptoms they’re experiencing.

If taking down documentation while observing a patient’s behavior, stick to factual observations and records those–not your professional opinion or interpretations as to what the patient’s behavior could mean. Sticking to the facts during observation will keep the process on an objective level instead of a subjective one.

Learn Shorthand & When to Use It

Technology has made it possible for nurses to now take their documentation as it relates to patients via computer instead of traditional pen and paper. Whether jotting down notes by hand or typing them on a keyboard, mastering the art of shorthand is the best way to save time and prevent a nurse’s hands from cramping up.

In addition to learning shorthand, nurses must also know when to implement it. When noting potential diagnoses, treatment and medication, shorthand is essential. No one wants to spend extra time spelling out those long medical terms. Knowing the abbreviations of medications, conditions and certain symptoms is a good way to expedite the documentation process without sacrificing the overall report.

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