One of the most important and critical tasks that every nurse must accomplish is meeting the clinical documentation standards. This is because, the entire treatment of a patient depends on this document, especially in a case where multiple doctors and experts are involved in the treatment. Here are some tips to ensure that you meet the required standards for clinical documentation.
Be clear and precise:
As a nurse, your duty is to make sure that everything you observe in a patient is documented. And it is also important that your handwriting is very legible so anyone who reads it can understand it clearly. Make sure that you use proper abbreviations wherever necessary and use correct definitions as well. Underlining or mentioning words or phrases that are important in bold is a good idea too.
Be a good observer:
To be able to meet the clinical documentation standards, you need to observe every move of a patient. Make sure that you are very attentive throughout the time you are with a patient who is under critical care. Each time you notice a reaction, symptom or an action by the patient, make a point to note it down the very moment. It may be hard to remember everything towards the end. Hence be real-time when you are documenting a patient’s behavior.
A clinical documentation is a legal document and could be used as an evidence in the court of law if the need be. Hence, avoid erasing anything that you have written and if you feel the need for correction, consider underlining the error and then brief about it in a fresh line. Erasures can raise suspicion in the court which is not a good sign for you and the hospital. So in the first place, it is better to avoid errors and be very sure before writing anything down on the chart.
Understand the rules and policies:
Though you have studied clinical documentation and the rules what to follow, it is a good idea to refer the guidelines before you attend to a patient. If you are a newly appointed nurse or lack experience, make sure to refer the guidelines each time you want to pen something down. The very first thing to do in a every medical treatment is to have a patient records just like in dental root canal treatment, Dentist will definitely ask patient’s details, background so that they will have a record on every patients they are handling.
Keeping up with time is very important if you are attending to more than one patient. You got to be fast in documenting patient behavior or activity. Do not confuse yourself and take a breather to refresh your mind and stay focused. It is important that you get to know all your patients. This will help you avoid confusions.