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Ep021: Nursing Documentation

nclex prep nursing podcasts

 

  • If it wasn’t documented, it wasn’t done!

 

        • Nurses are responsible for documenting many things. Some of which include:
          • Care plans
          • Medications (many facilities use barcode scanning)
          • Nursing notes
          • Assessments (focused, head to toe, vascular access devices, lines, tubes, airways, pain, sedation, restraints)
          • Patient education
        • Pay close attention to documentation training courses; the faster and more efficient you are at charting, the less time you spend in front of the computer
        • Have the mentality when you’re charting that you want whomever reads it in the future to have a clear picture of what was happening with the patient at any point in their stay while you’re caring for them.
        • Write like it’s going to be read in a deposition in the future
        • Always document the facts and things that you’ve seen or done, never assume anything
          • For example, if you walk into your patient’s room and they are on the floor and the patient says they fell..
            • Do not chart: “Patient fell.”
            • Chart: “Walked into patient’s room, noted patient lying on ground at the foot of the bed.”

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