Why is nurse documentation important

Do not use an abbreviation unless you are sure that it is commonly understood and in general use. For example, BP and VA are in general use and would be safe to use on records when commenting on blood pressure and visual acuity, respectively.

Do not speculate, make offensive statements, or use humour about the patient. Patients have the right to see their records! If you make an error, cross it out with one clear line through it, and sign. Do not use sticky labels or correction fluid. Remember, some information you have been given by the patient may be confidential. Think carefully and decide whether it is necessary to record it in writing where anyone may be able to read it; all members of the eye care team, and also the patient and relatives, have a right to access nursing records.

Keep the nursing records in a place where they can be accessed easily; preferably near to where the nursing team meet at shift change times. This will ensure that records are available for handover sessions and also that they are easily accessible to the rest of the eye care team.

The handover may take place with the patient present, if appropriate. Indeed, nursing records can only be accurate if patients have been involved in decision making related to their care. File the nursing records in the medical notes folder on discharge. Ensure that the whole team knows if nursing records are stored elsewhere.

Accurate records will contain observations of clinical outcomes, for example, how an elderly patient has benefited from his or her cataract operation or how skilled the patient is at instilling eye drops before discharge.

Such information can be used in clinical audit and reports on clinical activity. This contributes to research and performance data which can be used to monitor improvement in service delivery and outcomes, all of which ultimately contributes to VISION It is not only medical notes that are important; well-written nursing records will provide qualitative comment on treatment outcomes. National Center for Biotechnology Information , U.

Journal List Community Eye Health v. Documentation is critically important in cases that involve violence because the client record may be used as a source of evidence in legal proceedings. Therefore, as a nurse you must clearly and comprehensively document your detailed assessment. It is important that you incorporate direct quotes from the client and place them in quotation marks, even if they are expletives involving profanity and obscenity.

Photographic images are also necessary to document cases of physical and sexual violence. Consult your institutional policies about photography and record keeping, including guidelines related to designated devices for recording images and how the client is identified in the picture.

Skip to content Main Text. Documentation and Violence Documentation is critically important in cases that involve violence because the client record may be used as a source of evidence in legal proceedings. Previous: Introduction to Documentation. Next: Documentation Components. Share This Book Share on Twitter. To provide a structured and standardised approach to nursing documentation for inpatients.

This will ensure consistent clinical communication processes across the RCH. It is continuous and nursing documentation should reflect this.

Review of the EMR gives an overview of the patient. These tabs can be customised to meet the specific needs of your patient group EMR tip sheet link - coming soon. It is recommended that each ward standardises the layout of their activity bar based on their patient population.

To ensure required documentation for each patient is complete, use the summary side bar link EMR Req Doc tip sheet link -- coming soon. The nursing hub is a shift planning tool and provides a timeline view of the plan of care including, ongoing assessments, diagnostic tests, appointments, scheduled medications, procedures and tasks. The orders will populate the hub and nurses can document directly from the hub into Flowsheets in real-time. Orders are visible by the multidisciplinary team.

Management of orders is crucial to the set up and useability of the hub. Additional tasks can be added to the hub by nurses as reminders. All patient documentation can be entered into Flowsheets observations, fluid balance, LDA assessment throughout the shift. Clinical information that is not recorded within flowsheets and any changes to the plan of care is documented as a real time progress note. Progress note entries should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact, outcome and plan for the patient and family.

Real time notes should be signed off after the first entry and subsequent entries are entered as addendums. Want to add your voice to the conversation? Publish your own post here. Never miss a great event again! By signing up, you agree to our Terms of Use and Privacy Policy. Never miss the best stories and events! Get JewishBoston This Week. Share Tweet Pin Email Print. By Kveller. By Religion News Service. September Blues—or Maybe Not?

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