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7 Tips Every Nurse Should Follow for Patient Documentation

Career News July 18, 2013

While a nurse’s primary concern needs to be patient safety, he or she also needs to adhere to the seven key principles listed below concerning patient care documentation.

Proper Medication Documentation

Medication errors seem to be somewhat frequent and jeopardize patients’ safety. Besides harming the patient, these errors can be costly. These errors can lead to litigation and monetary awards to patients for the damages they suffered. Knowing what drugs are administered to a patient is essential. Prior to giving a medication to a patient that the physician has ordered, the nurse needs to know and then document several things:

•The way the medication should be administered
•The appropriate dosage for the patient’s condition
•Possible adverse reactions to watch for and any contradictions
•The purpose of the medication and its actions

Errors in Documentation

•Transcription errors
•Some medication abbreviations have been banned from use because of their similarity to one another.
•Mistaken interpretation of a medication due to illegible penmanship.
•If the nurse neglects to document that he or she has already given the patient his or her medication he or she could receive a second dose. This could happen during mealtimes or breaks when other nurses care for his or her patients during their absence.
•If an order is not transcribed properly, the patient may not receive the correct dosage or medication.
Nurses Must Monitor for and then Report Patient Deterioration

A nurse must make an initial assessment of his or her patient and then initiate a care plan. He or she has to continuously evaluate his or her patient’s condition. He or She must be sure to properly document this information and communicate how effective his or her current treatment is.

Effective Communication through Documentation and Beyond

When a patient is being transferred between caregivers, the nurse transferring the patient must give the nurse who is taking responsibility for the patient all the appropriate information related to his or her condition.
This information includes:

•How the patient has responded to treatment.
•Any changes that have been made to his or her treatment plan or condition.

Accurate Documentation in a Timely Manner

Timely and accurate documentation of a patient’s medical record are necessary for different reasons:

•It may be used for educational and research purposes.
•Medical records can be utilized as evidence in a legal proceeding. Careless documentation can make a negative impression on a jury.
•It is used to validate reimbursement claims from the insurance company.
•A medical record is actually a legal document that the states’ laws and regulations require.
•It is used as a means of communication among caregivers and ensures the continuity of care.

He or She Should Know and Then Follow His or Her Facility’s Policies and Procedures

A nurse must know and then follow his or her facility’s documentation policies and procedures. If he or she does not, he or she could put the facility at risk of a lawsuit.

Sign, Date and Time Every Entry

He or She should follow his or her facility’s policy regarding signing, dating, and adding a time to each entry.

Document All Pertinent Information

Should a patient decide to refuse treatment or not take his or her medication, the nurse needs to clearly document this in his or her chart. He or She should include in his or her documentation whom he or she contacted about his or her refusal.

If a nurse adheres to the seven tips related to patient care documentation and follows the policies and procedures set forth by the establishment he or she works for, he or she should have few problems related to his or her documentation procedures.

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