Mar 29, 2007, 08:18 pm
I might be able to help with basic documentation principles.
First up, you must date and time your report. Time must be in 24 hour clock, meaning that after 12 midday, you keep counting onwards. For example, 1pm would be written "1300 hrs', 2pm is "1400 hrs" and so on.
Next, because it's a nursing entry, you must writing "NURSING". Then you begin your report.
All entries must be easy to read, and should be made in black or blue pen (most nurses prefer black). Make sure you write in the third person, for example, rather than write "I showered Marjorie at 9am", you would write "Resident showered by 1 staff at 0900 hrs". Make sure you remain OBJECTIVE: no personal opinions. Keep it clinical, relevant, and short.
Once you've written your entry, it is very important to sign it off correctly. Write your signature, followed by your printed name in brackets, and your designation (AIN, EN etc). Make sure you don't leave any lines - run a line through any clear lines you might leave, to ensure no-one adds to your entry!
Nursing notes are a legal document. You must write what happened, what you did about it, any outcomes etc. We write notes for a number of very important reasons: (1) they justify our role (2) they cover our actions (if you don't document what you do, it didn't happen) (3) they allow nurses to communicate to each other and other team members.
Hope that helps, I'm more than happy to answer any questions.
Monika
