Otherwise, by presenting their documented notes that show where and when errors may have happened, nursing students learn better when teachers use examples from real-life experiences since these are ones that you have to record. Hospitals also benefit from having records on hand because if someone were ever to sue them, they proved medical mistakes occurred, and then doctors would need evidence to prove. The main point is Documentation protects nurses as well as patients, so make sure there’s an easy way to keep track.Īlso, this protects nurses as well with proper Documentation, they can’t be blamed for things they didn’t do or said incorrectly. In that case, nobody will know how long ago this happened, which could result in other health complications down the line. Suppose the nurse ever suffers a medical emergency and their condition is not known because they failed to document everything. You are also protecting your nurses by documenting all interactions with patients when they have visitors, new orders for care, or anything that may be important. You have to keep a record of everything to go back and refer to it in case of any questions. When Documentation is not done correctly, it can lead to possible lawsuits if there was an error or negligence on behalf of the nurse that led up to something wrong happening with their patient. As nurses, they must document their patient’s daily progress to provide for continuity of care. In simple words, Documentation is a record of a nationally organized account of the facts and observations about a particular subject. Documentation helps to ensure routines are followed and fosters communication among staff in the same and different disciplines.ĭocumentation in nursing is crucial for patients’ continuity of care, determining clinical reimbursement, avoiding malpractice, and facilitating communication between rotating providers. It is essential to document every step of the process, from the time medication is given by a nurse to recording refrigerator temperatures by the head cook. Conclusion on Why Is Documentation Important in Nursingĭocumentation is a necessity in almost every profession, but it has become a vital component of every employee’s role in health care.Benefits of creating Documentation in Nursing.How does having proper records help your patients?.What Kind of Information Do You Record?.Because of this, we are sharing this complete guide. You must understand why documentation is important in nursing to provide comprehensive care for your patients. The Documentation provides evidence-based information which can be used for future reference and research purposes. If each patient’s nursing record is incomplete before the transfer, it will negatively impact their wellbeing. It is almost impossible for them to remember everything they do and everything that happens during a shift. In reality, keeping good records is part of the nursing care they provide for their patients. A nurse in any setting needs to accurately document what they have done so that others who work with them are aware of all interventions. Nursing is a profession that requires the ability to care for patients and documents and communicate their treatments. When a nurse is busy with a busy working day and many urgent demands on her time, keeping nursing records may seem like a distraction from the actual work of nursing: looking after your patients.
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