By Chris Vinton, Medical Solutions Quality Assurance Specialist
One of the less exciting, yet most important parts of the nursing field is documentation. Documenting information properly is absolutely paramount to protecting you, your fellow nurses, the hospital, and your Travel Nursing company.
Having good documentation skills is essential to quality patient care, most importantly, because it protects your patients. Properly notating important information — such as medication administered or vital signs — will provide you with an overall picture of your patient’s health. Be sure to avoid general statements. Instead of writing “Administered 500 of saline” try writing “1100: Administered 500ml of normal saline using IV located at Median cubital vein.”
Granted, that entry is basically a novel when it comes to documentation terms and there are abbreviations. However, the second statement gave specific details and will give a much better view of the procedure or the patient’s health for you, the patient’s doctor and the nurse coming on shift after you! Even over-documenting small details that might seem meaningless could turn out to be significant and help uncover symptoms that may not have otherwise been caught.
In addition to patient protection, proper documentation protects you and your fellow staff! Even when the hospital staff does everything right, patients may not always respond to the care given. In which case, the patient’s hospital file and your documentation will go under a heavy amount of scrutiny. If things ever go really poorly, the patient’s medical record might be your first and only line of defense against a lawsuit.
Now, how to be thorough yet also brief? Each hospital does have approved abbreviations for medicine and many abbreviations are standardized across the industry. Be sure to check with your supervisor or preceptor and make sure you are using the correct abbreviation for the facility! You don’t want to be writing War and Peace every time you administer normal saline but at the same time, you do not want to under-document or incorrectly document treatment.
When going on a Travel Nursing assignment, be sure you are aware of what documentation system the hospital has. Some might have EMR and other hospitals might be old school and only use paper! Always be sure you make the time to document properly. As usual, documentation can’t be talked about without saying “If it wasn’t documented, it didn’t happen.” Always use good documentation to protect your patient and yourself!
Austin, Sally. “Stay out of Court with Proper Documentation: Nursing2015.” LWW. N.p., Apr. 2011. Web. 09 Nov. 2015.
Wang N., Hailey D. & Yu P. (2011) Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. Journal of Advanced Nursing 67(9), 1858–1875.