• E-mail
• Print
• RSS

Improve communication by educating nurses on notewriting

Ambulatory Safety Monitor, April 21, 2005

Want to receive articles like this one in your inbox? Subscribe to Ambulatory Safety Monitor!

AAAHC standards A7 and D1 and JCAHO's National Patient Safety Goal #2 require your facility to improve communication processes among caregivers. One process you can improve in your facility is educating registered nurses (RN) about how to write quality notes.

RN notes often include basic information about a patient's eating or bathroom routine. Doctors (MD) "aren't going to waste their time reading general information," says Sharon Eddy, RN, MSN, director of nursing at Natchez (MS) Regional Medical Center. "They want you to get to the point: signs, symptoms, and complaints." Instead of forcing MDs to read low-quality nurse notes, Eddy focuses her attention on educating the RNs about how to write better notes.

Tip: Hold training sessions on notewriting. "We have a veteran RN conduct regular training sessions," says Eddy. "The experienced RN trains new or struggling RNs to list key elements and problems and to lose the narrative in their notes." For example, unless eating and bathroom routines directly affect the patient's case, leave that trivial information out.

Eddy also has her RNs make daily rounds with the MDs. "While on the rounds, our RNs get a good idea of the information that's important to an MD," says Eddy.

Reminder: Like RNs, MDs need to make an extra effort. "If a doctor fails to read a vital RN note and something happens to a patient, the MD and the facility can be sued," reminds Eddy.

Want to receive articles like this one in your inbox? Subscribe to Ambulatory Safety Monitor!

• E-mail to a Colleague
• Print
• RSS
• Archive