Few things can save your job and reputation like your documentation. In instances where another clinician may question your judgment or activities, your documentation can indicate the date, time and other details necessary to prove that you acted in an appropriate manner.
Although nursing instructors attempt to teach proper and thorough documentation in nursing school, frequently new grads include either too much or not enough detail. A key to learning best documentation practices is to read other nurses’ notes. Although most facilities now use computerized charting due to new laws regarding the electronic medical record (EMR), you can check other nurses’ notes within your system. Additionally, some facilities (mostly nursing homes) still use paper charts.
Typically, all charting involves a lot of check-off boxes. In areas that require handwriting, remember that someone other than yourself may have to read your notes and that one day you may be called to testify as a witness. (more…)