Nursing

In the know: Document your care

Stressed Out Nurses Weekly, March 22, 2010

The clinical record needs to reflect an accurate and complete account of the care rendered. Like a book, the medical record should tell the story of the patient's care. It should have a beginning, middle, and end. Any reviewer who read the medical record should get a good clinical picture of the events, care, and patient outcome. There should be no incomplete flow sheets and/or graphic sheets, or lapses in progress notes. It should include the right date, time, and clinical status, as well as the clinical care provided. Here are some guidelines to ensure that your documentation reflects your good care:

  • Sign your name and credentials for every entry, even if it is just one line.
  • Document consent for or refusal of treatment in the record.
  • Never document a procedure or medication before it is administered
  • Use only abbreviations approved by the organization

For more tips, check out HCPro's book, Stressed Out About Your First Year of Nursing.

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