Documentation is such an essential part of nursing. To many it seems a waste of time. They’d rather spend their time with the patients, but in the interest of continuity, we have to be able to communicate information about the patient and the care we have given.
Documentation takes many forms in various institutions and facilities, but the basics include providing the most important points. If you can remember to answer the who, what,when,where,why and how your documentation should be accurate.
Here’s a sample case study and how to derive the information you need to include. I hope it’s helpful to those who struggle with charting.
photo from stockxchng.com by Pedro Simao