Documentation

LECTURSE BY:
RAHIMA MANGELEN, SALENDAB, BSN, R.N,
MEEQAT GENERAL HOSPITAL.MEDINA,KSA

1. RAHIMA MANGELEN, SALENDAB, BSN, R.N, MEEQAT GENERAL HOSPITAL

2. the nursing profession involves legalities when in comes to caring patients in all groups. These legal issues can only straighten when there is accurate DOCUMENTATION. The common term used in the field of nursing when it comes to documentation is CHARTING The most integral part of the nurse’s responsibility is the CHARTING FOR NURSES

3. Documentation- in nursing is a key factor in our role and responsibility as a patient care advocates. It is critical for determining if the standard of care was rendered to a patient to defend prior nursing actions. Failure to chart, omissions, and poor communication are hard to defend Charting - the act of compiling data on clinical records or charts (computerized or paper). The charts are updated regularly to keep physicians and other health care workers advised of changes in the patient's condition. The data usually include fluctuations in temperature, pulse, respiration, other variable factors, and much more, including all nursing care.

4. Be extra careful when you think you are "too busy." Be aware of critical times such as: abnormal vital signs codes transfers change of nursing shift or patient hand over (endorsement) taking verbal orders noting physician’s orders verifying medication orders date & time of each procedure

5. The nurse must report critical values to the physician within 30 minutes .

6. Avoid general statements. Beware of general statements that can be misconstrued . For example, you wrote “Seen by ER doctor. ” “Seen by Surgeon” Did you mean: Seen by Dr. Moh'd ali ? Seen & Examine by surgeon (Seen & examined by Surgeon Dr. Adel).

7. Late entries and any corrections entered should be per policy and procedure.

8. Charting patterns including flow sheets will be reviewed. “Too perfect” charting may raise doubts. Patient assessment such as fall risk or skin assessments, & new onset of pain must be carefully performed and documented. Failing to do so is a common error

9. Consult the nursing policy and procedure for accepted abbreviations . Sign each entry correctly, including date and time. An illegible signature may lead to all nurses on duty being named in order to “cast a wide net.”  Date and time are crucial when creating a chronology of events.  

10. To avoid all these troubles, it is important that you pay attention to nursing documentation. It may not just save your patients' lives—it might save your career, too.