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…
A Documentation Sample
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…
Need Help With Documentation?
Today I rediscovered a great book I read a few months back called Writing for Nursing and Midwifery Students by Julio Gimenez. Dr. Gimenez is a Professor at Middlesex University in north London. He teaches academic writing to nursing, midwifery and business students. This book is terrific at teaching nurses how to examine the care they have given and to document it by focusing on “the five w’s and an h” otherwise known as who, what, when, where, why and how. Check it out….it’s a must for your nursing library!