Accurate and comprehensive nursing documentation is critical to provide superior quality care to patients. Quality care can be ensured with excellent team effort. Nursing charts should be easily accessible to physicians and other clinicians to help them understand the status of the patient’s condition and care. Proper documentation with effective nursing transcription ensures that each patient’s individual needs are clearly communicated to team members. This will also help nurses to avoid medication errors. Here are some good documentation practices that can in turn ensure quality care and patient safety.
Chart Objective Information
You should accurately document what you see, feel, smell and hear. If you are documenting what someone else observed, mention that in the notes. Exactness of documentation is vital. For instance, if a patient refuses to take medications and throws them away, you should not document “the patient is not taking medications properly.” Make sure that you document “the patient refused to take medications and threw them away.”
Chart Immediately after Giving Care
It is better to chart as soon as possible after providing care as you can remember everything vividly and document correctly to avoid medication errors. Besides, it is required to report critical values to the physician within 30 minutes. You should follow the facility’s safe plan in case the physician can’t be reached. Even if you are busy, be aware of critical items (such as abnormal vital signs, transfer, nursing shift or patient hand offs, taking verbal orders, verifying medication orders and notifying physician’s orders) and document everything as fast as you can.
Use Only Approved Abbreviations
Do not use abbreviations that are non-medical or not approved in your chart. Avoid using texting language as well. Although abbreviations may save your time, make sure that they are correct and do not end up as a threat to the patient.
It is very important to review the chart to find out inadvertent errors and correct them. This will not only help you to correct your mistakes, but also eliminate the mistakes made by your co-workers.
Document Follow-up Care
You should document in what way you followed up a medical situation with the appropriate patient care. When the patient’s status changed and you have notified the physician, document the exact change in the patient’s status and also that you have notified the physician. Document the changes made by the physician and how the patient responded to those changes.
Be Careful with Late Entries
Be very careful with adding late entries. They should be documented per policy and procedure. Late entries should not be squeezed into the chart to appear as if they were documented on time. The same principle applies to corrections as well.
You should highlight allergies and fill out flow sheets completely. If you observe new onset of pain, evaluate thoroughly and document it appropriately in your chart. Relying upon transcription services a midst your busy schedule would be a great relief and help you generate more accurate documentation. You can record all your observations, interactions with patients and caregivers, and services provided and have the recordings transcribed. With transcription provided by professional transcriptionists and thorough review by editors and proofreaders, you can have the documentation prepared and returned to you within the required turnaround time. In this way, you get to save a lot of time while also ensuring the accuracy and completeness of your documentation.