What are some ways to improve your nursing documentation?


Quick Answer

To improve nursing documentation, don't chart ahead of time, pay attention to the most crucial charting times and write legibly, according to Nurse Together. Not being able to read what a nurse wrote is a common issue with charting that makes it difficult to properly care for a patient.

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Full Answer

Some of the more urgent things to write in a chart in regards to a patient include transfers, codes, abnormal vital signs and nurses changing shifts, notes Nurse Together. Other critical times for the chart are taking verbal orders, writing doctor's orders and verifying medication orders. Any critical information in the chart needs to be reported to a doctor quickly, preferably within 30 minutes of the event.

Nurse documentation should also not include general or vague statements, according to Nurse Together. This can cause confusion, and a doctor or other nurse might give the patient the wrong care because of it. If no further details are available, simply write that there were no additional orders or information available at that time.

The nursing documentation needs to be easy to read, free of spelling and grammatical errors, and free of errors, says Nurse Together. Try not to make too many mistakes that need to be crossed out. Write in blue or black ink to make it easier to read, and ensure the information is accurate before writing it in the chart. Also, ensure all information in the chart is objective.

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