Documentation Of medical records

1. Never document nursing care before it is provided.*
This contributes to inaccurate record about patient care. It leads to making inappropriate decision by Drs. Eg. “Rectal washout done” whereas it wasn’t executed.
2. Do not routinely document care rendered by others.*
Some of us fill up the cardex with doctors documentations. Some copy the drugs prescribed during ward round on the cardex without inserting a single nursing intervention for that particular shift.
Your nursing intervention depends on your nursing findings not medical findings. Eg. You admitted a patient with fractured leg, the Dr wouldn’t have paid attention to his bowel and nutritional aspect.
We record urine and bowel output daily but we don’t take independent decisions on them. We only wait for the Dr to come and prescribe “do rectal washout” or “keep intake/output chart” , “weigh pt daily”
3. Never leave blank spaces between entries.*
Sometime we leave spaces for previous shift documentation. It is wrong. All spaces must be cancelled or filled to avoid insertion of culpable notes by unknown persons
4. Do not chart that a patient is in pain unless you have intervened.*
On no account should a nurse document “Patient complains of radiating chest pain,” or “patient had high temperature”, without subsequently documenting what was done about the issue.
5. Do not document subjective descriptions.*
Always obtain accurate vital sign checks, intakes and outputs, and other objectively measurable data and record this information in a timely manner. Don’t use phrases like: “Patient’s blood pressure is really high.”
6. Do not openly criticize the care that was rendered by a coworker.*
Berating a fellow nurse in your report will accomplish nothing other than perhaps fuel the fire of probe by anyone who happens to read the chart at a later date.
7. Do not mention short-staffing or inadequate equipment in the report*
Always concentrate on your intervention. Your report doesn’t need lamentation or expression of dismay over challenges. Remember mentioning those things may not completely exonerate you when found wanting. Don’t write “there was no oxygen on the ward” or “There was no thermometer on the ward” in your report.
8. Do not ever document the existence of incident reports.*
The incident report is an internal document meant to facilitate improvement of systems and processes within the healthcare facility(use internal memo).
If you indicate that there was incident on the ward in your report, that incident become subject to probe by investigators.
9. Your report must be engaging in nature*
Don’t write that “I was called see the patient”, “My attention was drawn by patient relation”.
You are a nurse not doctor, your documentation must show that you didn’t abandon the pt to the relatives all through
*Be a smart Nurse*
*Be an intelligent Nurse*
*Always report smartly*
*Be conscious of litigation*
*Thank You*

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Updated: October 28, 2017 — 1:53 pm

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