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Tips for Documentation

Posted Feb 19 2009 6:30pm


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 when you sit down to chart.

photo: Zeth Lorenzo stockxchng.com

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