Comprehensive records are essential in healthcare and nurses need to dedicate time to documentation. Nurses are subject to increasing scrutiny regarding their record-keeping. Legislation such as the Human Rights Act and the Data Protection Act has increased the profile of, and access to, health records Dennemeyer, ; Sainsbury Centre for Mental Health, , while patients are increasingly willing to complain about their care. Whether complaints are resolved by health care providers or settled in court, comprehensive records are essential. It is important, therefore, that nurses keep abreast of legal requirements and best practice in record-keeping. The Code of Professional Conduct NMC, a advises that good note-taking is a vital tool of communication between nurses.
Wound Documentation Dos & Don'ts: 10 Tips for Success
Ten Dos and Don’ts for Wound Documentation | WoundSource
If you are a registered nurse who dreads documenting the care you provide to patients—you are not alone. Many nurses dread documentation because it takes them away from patient care but proper documentation can help nurses avoid medication errors and legal troubles. Documentation allows you to demonstrate how you provided the patient with a standard of care that meets the institutional and board standards in the state where you practice. Did you know that the medical record might be the only evidence presented in a lawsuit? As nurses, we know that failure to provide timely, accurate documentation is unsafe, irresponsible nursing care. This is true even when we are caring for highly acute patients in an understaffed setting.
Tips for Great Nursing Documentation
In the first scenario, meet Harlow. The team has a well-established codebase, a great working environment, and a robust test suite. Join the O'Reilly online learning platform. Get a free trial today and find answers on the fly, or master something new and useful.
Speaking of templates, you can easily find numerous templates related to the practice of health care, such as the Health History Questionnaire and the Patient Satisfaction Survey. The information in this type of documents must be integrated for the meaning in a nursing election. The information you collect from your answers will give you the opportunity to respond from wisdom instead of emotions or perhaps show you that changing the subject would be the ideal strategy for both. Be precise with what you are including in your documentation and avoid putting your opinion on the person. It was found that paper documentation is inferior in contrast to electronic documentation.