Nursing is a field that requires you to be accurate. You must be able to write fast, filling out charts and analyzing data properly. Nurses often need to record conversations between patients and doctors and also to defend their own reports, proving that their records are correct. We decided to help you a bit so we prepared some useful information and tips that may help everyone who is going to become a nurse.
This advice may seem obvious, but you must understand that accuracy is extremely important in everything associated with nursing work. Not only need you to be accurate when noting details of treatment procedures and medication, but you also must record and report various events, including patients expressing concerns about treatment or doctors’ orders. If you’re not accurate in your reports, this will lead to various inspections and investigations.
Suppose you change a patient’s dress. You can make a record that looks like this:
“Did dressing change.”
If this is all you managed to write, a person who reads it will have a lot of space for various interpretations. If you want to be really precise, this record must look as follows:
“Changed dressing, cleaned a wound with antiseptics, applied tetracycline ointment, covered with gauze, using silk tape. Patient felt well.”
By looking at this record, anyone can imagine a clear picture of your actions, taking into account every step. Here you provide all necessary information on used materials. However, it’s often necessary to describe the wound and how a doctor changed any prescriptions.
Avoid expressing personal opinions and emotions when writing. You must distance yourself from the situation you are in and focus on facts only, with no emotional interpretations or reactions.
“Patient is crazy.”
This is a subjective and inappropriate opinion that shouldn’t be expressed. Moreover, nurses are not responsible for diagnosing mental disorders. This is what such a record must look like:
“Patient moves chaotically, pounding the bed with his fists, breathing rapidly, and yelling something indistinct.”
By looking at this record, everyone can see a clear picture of what actually happened, being able to draw his or her own conclusions and to take necessary actions.
Don’t Forget About Your Audience
Numerous investigations and inspections are a part of the everyday routine for every nurse. Prepare for the fact that your readers will perceive your records critically, searching for inconsistencies and various mistakes. Thus, if you don’t want to have problems with such readers, you must be very accurate in your reports and provide only accurate data in charts that you fill out.
We showed you two examples of really bad reports. Both of them could be used against the nurse in court or lead to some disciplinary actions. Reading the first record, expert witnesses would notice the fact that the nurse didn’t specify any used materials nor described the condition of the patient. In turn, these suspicions raise new suspicions about the nurse following a doctor’s instructions.
As for the second record, the nurse didn’t describe a patient’s actions. There was no single detail by which we could understand why the nurse called the patient crazy. Such a report will likely cause charges for negligence.
Both of these examples are what you should avoid in any circumstances because doing such incorrect records, you risk losing your license. Don’t let your laziness or emotions take your job and remember how important your profession is!