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Ahead we'll define what proper documentation is and why it's so important, explore common documentation errors, and look at some dos and don'ts of proper documentation. Their written accounts are critical for planning and evaluation of medical interventions and ongoing patient care.
Nursing documentation must provide an accurate, complete, and honest account of the events that occurred and when.
Environmental conditions, distractions, lack of training, infrastructural problems, and lack of communication can all lead to documentation errors.
Nurses learn proper documentation procedures during their initial training, but nurse CE courses can provide important refreshers and updated information pertaining to documentation.
Thorough, accurate documentation is important for communication and continuity of care-everyone involved in the delivery of care requires information about the patient.
Documentation is important for quality assurance-the information contained in patient charts is often used to evaluate the quality of service and the appropriateness of care delivered by nurses.
#9: Failing to document new symptoms or conditions You should document any new condition where appropriate, including the time of occurrence, the action you took, and the patient's response.
Nurses need to draw a line through blanks that are not applicable on documentation forms, and initial them.
#2: Writing sloppily or illegibly This requires little explanation.