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Ep021: Nursing Documentation

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  • If it wasn’t documented, it wasn’t done!


        • Nurses are responsible for documenting many things. Some of which include:
          • Care plans
          • Medications (many facilities use barcode scanning)
          • Nursing notes
          • Assessments (focused, head to toe, vascular access devices, lines, tubes, airways, pain, sedation, restraints)
          • Patient education
        • Pay close attention to documentation training courses; the faster and more efficient you are at charting, the less time you spend in front of the computer
        • Have the mentality when you’re charting that you want whomever reads it in the future to have a clear picture of what was happening with the patient at any point in their stay while you’re caring for them.
        • Write like it’s going to be read in a deposition in the future
        • Always document the facts and things that you’ve seen or done, never assume anything
          • For example, if you walk into your patient’s room and they are on the floor and the patient says they fell..
            • Do not chart: “Patient fell.”
            • Chart: “Walked into patient’s room, noted patient lying on ground at the foot of the bed.”
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Date Published - Nov 4, 2016
Date Modified - Jun 25, 2018

Jon Haws RN

Written by Jon Haws RN

Jon Haws RN began his nursing career at a Level I Trauma ICU in DFW working as a code team nurse, charge nurse, and preceptor. Frustrated with the nursing education process, Jon started NRSNG in 2014 with a desire to provide tools and confidence to nursing students around the globe. When he's not busting out content for NRSNG, Jon enjoys spending time with his two kids and wife.

One Comment

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    patience uket

    hi, is these all one needs on documentation for the nclex exams?