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How-to Conduct Proper Nursing Documentation in the Hospital

By Edited Oct 27, 2013 0 0

Throughout a nursing student's tenure in nursing school they are subjected to the importance of nursing documentation throughout. Beginning with their very first initial morning clinical rotation, they are afforded great opportunity to, not only care for their assigned patient(s), but to also thoroughly document on the care they provided. Fortunately, nursing textbook after textbook has been written that directly reference the importance of proper nursing documentation in the clinical setting. Where legal issues abound in droves, a registered nurses ability to conduct proper, and accurate, documentation serves a variety of purposes. Besides helping to maintain a thorough continuity of care, as each new shift assumes accountability for patients, proper documentation also helps to cover you in the event that legal options are pursued in a variety of situations.

While I went through nursing school, my class was continually reminded of the importance of adhering to a strict nursing documentation standard. My class was taught that, of all the many functions of a registered nurse, which nursing documentation was arguably one of the most important tasks, and, oftentimes, under the pressures of rigorous work schedules, it wasn't given the time that it clearly deserved. In a profession governed by communication, nursing documentation is one of the best tools of effective communication that a registered nurse has at their disposal. Not only does accurate nursing documentation help to foster understanding, but my nursing class was constantly reminded of the legal implications governing appropriate, or inappropriate nursing documentation. To say that they scared us with thoughtful, real-life, horror story scenarios, would be an understatement, however, it was clear as to why our professors would place so much emphasis on such an important consideration.

In order to satisfy such a strict nursing documentation standard, it didn't take very many clinical rotations for my class to figure out the many characteristics of proper documentation that our professors were looking for. In general, these characteristics span across the field of nursing and deal with how to effectively communicate, through writing, to other people in general. At the forefront of characteristics of proper documentation is a registered nurses ability to write legibly. Unfortunately, while this may appear to be a simple step to many, one may be utterly surprised at just how many registered nurses, or physicians for that matter, don't adhere to a strict standard of legibility. Because proper documentation is essentially a detailed legal record, constructed over time, maintaining this legibility is paramount to the effective flow and continuity of care from one shift to the next.

Another characteristic that proper and effective documentation must achieve is that it be accurate and factual. Great time is expended, in nursing school, to allowing nursing students ample opportunity to get to know their assessment equipment, and to fine tune their assessment skills. As they continually engage in a process of observation, and analysis, by the time graduation comes around, they should have a firm understanding of how to translate what they observe into real accurate and factual data that is reflected in their documentation. Rather than simply conveying that a patient's vital signs are outside of what one would consider 'normal', an adherence to accuracy is a nursing documentation standard that will be addressed when one provides the actual raw data of vital signs. By providing actual numbers, a continuity of care and communication is maintained because the next nurses to assume care can simply reference old entries to see how, and to what extent, a patient's vital signs have really changed over time.

A common occurrence in the clinical arena is that patients are often referenced as being stable or unstable. Unfortunately, one needs to conduct their documentation with the inherent assumption that someone who has never taken care of your patient may assume responsibility. While this may, or may not, be the case with you patient, you should approach your documentation in such a way that leaves very few questions in the mind of the next caregiver. In this case, a registered nurses ability to relate a patient as being stable or unstable simply doesn't provide the accurate baseline data required to know how a patient truly is. By saying that, a void of information is left regarding just about every aspect of care and this should be avoided, although it does appear to be a tendency of many registered nurses who a currently practicing in the clinical setting.

Not only did my nursing professors express the importance of accurate and legible documentation, but they also conveyed a certain nursing documentation standard be upheld through timely documentation. Just like many things in life, we tend to forget important and pertinent information whenever we become so pre-occupied with managing a variety of tasks. Oftentimes, this is a situation that is not so uncommon for a registered nurse to face, especially with increasing schedule demands and insane nurse to patient care ratios. At times, it simply may not be possible to chart or document immediately after care has been provided. For this reason, it may be necessary for a registered nurse to consider carrying around a pen and notebook or tablet in order to write down essential data as they go room to room caring for their patients.

In order to tie in all of these characteristics and adhere to a proper nursing documentation standard, my professors would also convey the importance of being thorough. Not only should a registered nurse adhere to strict standards of legibility, accuracy, and timeliness, but one's documentation must also be complete, or thorough, in detail. This doesn't necessarily mean that your documentation should be lengthy, but rather that it should be concise and to the point, and it should leave very little room for misunderstanding or confusion.

With such strong emphasis on current HIPPA regulations, you documentation should also be confidential. While simple in theory, breech of patient confidentiality is, unfortunately, one of the most common occurrences in the healthcare setting. Even the most skilled nurse, with years of nursing practice under their belt, may simply leave a chart open, and unattended, on their medication cart during their early morning medication pass. This is unacceptable and failure to adhere to confidentiality could certainly render all your other efforts null and void.

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