![]() It's imperative that you document and complete your patients' charts throughout the day to establish a record that includes the important details that can help another health care professional understand a patient's status. Take notes in real timeĭue to the various tasks you may be responsible for and the number of patients you may provide care to, it can be challenging to remember everything that's happened in a day with any particular patient. Here are 10 practical tips you can implement to ensure the accuracy of nursing documentation during patient care: 1. Related: Detail-Oriented Skills: Definition and Tips 10 nursing documentation tips ![]() Working to ensure proper and ethical documentation can improve and impact the care of the patient and the ability of others on the health care team to provide proper treatment. Many health care employers have specific documentation protocols for you to follow to ensure the best care possible for patients. These documents serve as an important communication method for those involved in a patient's care team.ĭocumentation also helps managers and hospitals verify that a nurse has followed guidelines during the administering of medications and treatments. Nurses work to create these charts and document all patient updates from vital signs to the patient's pain level, as well as any progression of symptoms or emergencies a patient experiences during their stay at a hospital. Why is accuracy important in nursing documentation?Īccuracy in nursing documentation is important because doctors, nurses and health care providers rely on the information in a patient's chart to perform their work, which may include developing treatment plans, administering medications or consulting with other specialists. In this article, we discuss the importance of this type of record-keeping and provide a list of 10 nursing documentation tips you can use to ensure that patients' charts remain clear, concise and comprehensive. Learning how to create and maintain proper nursing documentation ensures the ability to develop treatment plans, accurately assess the patient's needs and discuss a diagnosis with the patient and their family. Having detailed and complete records helps to keep all parties, including the patient, patients' families, doctors and other nurses, informed of relevant information regarding care and protocols. Nursing documentation provides a crucial communication tool for health care teams as they work to treat patients.
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