Nursing documentation is essential for good clinical communication. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice.
Nurses face new issues and problems each day and regularly make decisions on patient care. Each decision is potentially subject to review with the public’s increasing awareness of their rights and tendency to litigate. Amid the stress of a working day, it is easy to see how record-keeping might be seen as a chore that gets in the way of patient care. However, it is an integral part of care.
Nurses must allocate time for both hands-on care and documentation, as it is the two together that constitute total patient care. If record-keeping is seen as a chore, there is a risk that the documentation will fall short of the standard expected of a professional.
To help nurses meet the regulatory requirements of legal and clinical documentation, the following must be observed:
- Write legibly or print neatly. Illegible entries can cause misunderstanding leading to errors.
- Use permanent ink. The use of colored ink aside from black or blue ink will depend on hospital policy.
- Write entries in consecutive and chronological order as soon as care has been provided. Be factual and specific.
- Give the date and time of every entry; sign your entry with your full name and position title. The signature clarifies who is responsible for the care.
- Describe the care provided and the patient's response to it, Include the patient and family's response to health teaching.
- Promptly document any change in the patient's condition and the actions taken based on that change. Use patient and family quotes.
- Chart only for yourself. Do not chart in advance as patient's condition may change anytime.
- Correct errors promptly as these may lead to errors in treatment. To correct an error, simply draw a line through the error and write the word "Mistaken Entry" above it. Sign your name, and write the date and time this was done.
The patient's nursing record provides a correct account of the treatment and care given and allows for good communication between you and your colleagues in the eye care team. Keeping good nursing records also allows us to identify problems that have arisen and the action taken to rectify them.
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