Documentation For The Nursing Professional

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Documentation for the Nursing Professional Lindsay Wishmier Nursing 232 Professor Steve Keiser October 29, 2009 Documentation for the Nursing Professional Documentation is a critical aspect in nursing. Documenting covers everything in regards to a patient’s care and stay in a facility. There are many things that need to be covered when documenting the care of a patient. Most of these things are related to treatments, medicine, procedures, doctor visits, and problems of the patient. There are also many skills to take into account when documenting. A patient’s chart is filled with information from all aspects of their care. Looking through the chart, information is gathered from other health care individuals on their treatment of the patient. Documentation can be a big source of communication, when staff is not able to be face to face. Documentation needs to be relevant and have important information included, without going into the color of the patient’s shoes. Documentation is one of the most important responsibilities of all health care providers. It’s a means of communicating among health care team members and the primary way by which nurses record factual information about a patient’s status and the care provided – from the time of admission to follow-up after discharge (Lippincott 2007). The importance of documentation is critical. As stated before it is a legal document. So think of documenting like presenting your patient to a lawyer and even a judge. Basics need to be included within a certain degree as well as the importance of care. Documentation needs to always be started with a date and time of entry. Try to document as soon as possible to avoid missing critical information. Include documenting what the patient tells you; quote the patient directly (Mosby 2006). Document what you assess and what you do, following with the

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