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Expert spotlight: Critical thinking skills essential for proper nursing documentation

Nurse Leader Weekly, September 21, 2009

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This week, Shelley Cohen, RN, BS, CEN, founder and president of Health Resources Unlimited, offers advice for teaching nurses critical writing skills.

Q: What role do critical thinking skills play when charting?

A: Critical writing is as important as critical thinking. Good documentation is a vital part of patient care and nurses need to be able to validate in the written medical record what they did or what they chose not to do. Identifying a patient problem, potential consequences, and necessary actions are vital elements of critical thinking for nurses. However, without appropriate and timely documentation, there is no written record of what occurred.

Remind nurses that charting mistakes can lead to allegations of negligence. These are the most common charting errors:

1. Failure to document pertinent health or drug information
2. Failure to record nursing actions
3. Failure to record medications given
4. Recording on the wrong chart
5. Failure to document a discontinued medication
6. Failure to document drug reactions/changes in patient's condition
7. Improper transcriptions of orders or transcription of improper orders
8. Writing illegible or incomplete records

Read the rest of this post here.

Editor's note: Do you have a question for our experts? Email your queries to Senior Managing Editor Rebecca Hendren at rhendren@hcpro.com and see your name in print next week! In the meantime, head over to our Web site and view a growing collection of advice from our experts.

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