When a nurse is busy with a busy working day and many urgent demands on her time, keeping nursing records may seem like a distraction from the actual work of nursing: looking after your patients.
Nursing is a profession that requires the ability to care for patients and documents and communicate their treatments. A nurse in any setting needs to accurately document what they have done so that others who work with them are aware of all interventions.
In reality, keeping good records is part of the nursing care they provide for their patients. It is almost impossible for them to remember everything they do and everything that happens during a shift. If each patient’s nursing record is incomplete before the transfer, it will negatively impact their wellbeing.
The Documentation provides evidence-based information which can be used for future reference and research purposes. You must understand why documentation is important in nursing to provide comprehensive care for your patients. Because of this, we are sharing this complete guide.
What is Documentation?
Documentation is a necessity in almost every profession, but it has become a vital component of every employee’s role in health care.
It is essential to document every step of the process, from the time medication is given by a nurse to recording refrigerator temperatures by the head cook. Documentation helps to ensure routines are followed and fosters communication among staff in the same and different disciplines.
Documentation in nursing is crucial for patients’ continuity of care, determining clinical reimbursement, avoiding malpractice, and facilitating communication between rotating providers.
In simple words, Documentation is a record of a nationally organized account of the facts and observations about a particular subject. As nurses, they must document their patient’s daily progress to provide for continuity of care.
When Documentation is not done correctly, it can lead to possible lawsuits if there was an error or negligence on behalf of the nurse that led up to something wrong happening with their patient.
Why Should You Be Documenting?
You have to keep a record of everything to go back and refer to it in case of any questions. You are also protecting your nurses by documenting all interactions with patients when they have visitors, new orders for care, or anything that may be important.
Protecting Nurses
Suppose the nurse ever suffers a medical emergency and their condition is not known because they failed to document everything. In that case, nobody will know how long ago this happened, which could result in other health complications down the line.
The main point is documentation protects nurses as well as patients, so make sure there’s an easy way to keep track.
Also, this protects nurses as well; with proper documentation, they can’t be blamed for things they didn’t do or said incorrectly. Hospitals also benefit from having records on hand because if someone were ever to sue them, or a nurse for malpractice, they prove medical mistakes did or did not occur.
Otherwise, by presenting their documented notes that show where and when errors may have happened, nursing students learn better when teachers use examples from real-life experiences since these are ones that you have to record.
What Kind of Information Do You Record?
In the nursing profession, every step you take is significant for a patient’s life and your own. That is why it is necessary to keep track of all the information you gathered about a patient, the medication they are taking, etc. You should also record any changes in their condition with time so that if anything happens, you can refer back to old records for help or diagnose them again.
In today’s world, where everything is being digitized and transferred from one place to another virtually, many new devices are coming out every day, which makes recording much more straightforward.
One such device would be an electronic health records system (EHR). It makes your work easier because you no longer need paper charts at the nurse’s stations anymore.
But although EHRs save the nurse some trouble by providing an overview of data like blood pressure and heart rate, it can also be quite dangerous because there is no way to tell who may have accessed the data.
How does having proper records help your patients?
Now it comes to the main point about how keeping documentation can help you. The well-documented records can help you to identify the patterns of your patient’s health. It also helps in providing a clear picture of their mental status and physical condition. This way, it becomes much easier for you to work on preventive as well as curative measures.
The documented recordings do not only help to keep your patients healthy, but they even help you in getting an idea about how others’ care is going on with them, i.e., what changes have been happening since when.
The best thing about having proper Documentation is that now there will be no discrepancies between different healthcare providers’ notes because every detail has been recorded correctly, and everyone knows where everything belongs.
Benefits of creating Documentation in Nursing
When we talk about benefits, it could be following:
- Reducing the chance of malpractice lawsuits,
- It is ensuring patient safety through accurate and complete Documentation.
- Record of medicines and treatments given to patients
- Improves the quality of care provided by hospitals.
- Allows for better communication with other healthcare providers and staff in a hospital setting
- Safety measure
The most important reason we should keep records is to ensure that there is a record of what was done if something goes wrong or somebody needs it. It can be used as evidence during legal proceedings, such as malpractice lawsuits or court cases.
This is a significant undertaking that requires accuracy and completeness when documenting patient treatment.
Patients are also protected if their medical records exist in electronic format because they provide proof regarding medications administered to them without needing the original containers to validate this information.
Recordkeeping allows physicians to communicate more effectively with other healthcare providers and staff within a hospital setting; it improves the overall quality of care delivered at hospitals, minimizes risk through accurate Documentation, facilitates continuity of care among healthcare personnel.
Conclusion on Why Is Documentation Important in Nursing
Documentation is a critical part of the healthcare field. It’s an opportunity to create and maintain records used as evidence in patient care, research, education, or legal proceedings.
By understanding what makes good nursing documentation so valuable to professionals and patients alike, you can better prepare yourself for your career and improve people’s quality of life.
More Resources
- Meaningful Use and the Continuity of Care Document
- Why Is the Nursing Process Important?
- Are Nurse’s Notes Becoming a Lost Art?
- Top Medical Abbreviations and Short Hand Fresh RN
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