Documentation do's and don'ts.
نویسنده
چکیده
Do read the nurses’ notes on the patient before caring for him and before charting your care. Do have the patient’s name and hospital number on every sheet. Do use correct spelling, correct grammar, and concise phrases. Do make entries in consecutive order. Do write the complete date and time of each entry, using am/pm or military time. Do sign each entry using your professional signature. Do indicate patient non-compliance and do use direct patient quotes when appropriate. Do use accepted hospital abbreviations. Do document nursing action taken following indication of a need for action. Do continue documentation of problems until resolution. Do document all physician contacts. Do document patient teaching. Do use only hospital-approved forms for charting. Do write neatly and legibly and use only black ink. Don’t begin charting until you check the name on the patient’s chart. Don’t pull a chart by room number only. Don’t backdate, tamper with, or add to notes previously written. Don’t write in margins. Don’t write relative statements such as, “wound is healing.” Instead, describe the wound. Don’t use medical terms unless you are sure of their exact meaning. Don’t wait until the end of the shift to chart. Don’t chart for anyone else, especially for nursing action performed by another nurse. Don’t erase or obliterate errors. Don’t skip lines between entries or leave space for others to chart. Don’t leave space for your signature. Don’t make derogatory remarks about the patient. Instead describe his/her behavior. Never write “incident report filed.”
منابع مشابه
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عنوان ژورنال:
- Nursing
دوره 23 8 شماره
صفحات -
تاریخ انتشار 1993