Tips for Documentation

Documentation is such an important part of nursing. Yes, I know, you’d rather be spending that time with the patient, but communication is an important part of nursing. Documenting the care you gave, the patient’s response and your observations is vital to optimum care.

Stop thinking about it as a chore and think of how what you write will help improve the quality of care and the patient’s outcomes. It has to be done just like any of the other procedures you put off till the last minute. Learn to do it well and it’ll be much easier.

Here are a few important Do’s and Don’ts for you to remember when you sit down to chart.

photo: Zeth Lorenzo stockxchng.com

One Comment

  • Vincent Bautista

    I sure do hate documentation especially when I have LOTS of patients assigned to me but I know that it’s for the patient’s well being so I do my best to be descriptive and accurate in my documentation.