Documentation is an essential part of your role as a nurse. You need to have good documentation skills to ensure patients get the appropriate care. An error could lead to communication issues at best and serious consequences for your patients at worst.
It’s common for nurses to think documentation is time-consuming and burdensome, but taking the time to document your interactions with patients and the things you have done on your shift is essential to keeping healthcare services as helpful and effective as they can be.
Proper documentation is necessary, and it can be a hallmark of how seriously you take your role as a nurse. Building your documentation skills helps you become a better communicator and ensures you’re doing your best for each and every patient you work with.
The Importance of Proper Documentation
As a nurse, it is essential to understand the importance of comprehensive and accurate documentation in patient care. Nurses need to prioritize documentation as a vital aspect of their practice to uphold professional standards and provide safe and effective care to their patients.
Quality Care
Accurate and thorough documentation is essential for quality assurance and performance improvement initiatives within healthcare organizations. By documenting all assessments, interventions, and outcomes, nurses can identify areas for improvement in their practice and contribute to the overall enhancement of patient care. With good documentation, nurses and other clinicians know exactly what’s going on with the patient and can support diagnosing or treating the patient more effectively.
Improve Communication
Nurses must be diligent in documenting all aspects of patient care, including assessments, interventions, medications administered, and any changes in the patient’s condition. Proper documentation improves communication within a healthcare team. If a nurse is starting or ending a shift, having documentation ready means your patient will continue to get the high level of care they need around the clock.
Ensure Safety
Another reason to maintain good documentation practices is because of audits done by the credentialing department. Credentialing bodies will look at documentation to ensure healthcare facilities and staff members are practicing safely. Part of the reason for this is to maintain good patient care practices and prevent accidents or injuries, but another reason is to be certain that facilities hire those with the right training to run the facility effectively.
Good documentation also protects you. Documentation issues have the potential to affect a nurse’s license. Errors, or a lack of documentation, can lead to disciplinary action as well as license rescissions.
The Risks of Poor Documentation
Poor documentation practices directly impact the quality of care patients receive, nurses’ ability to do their job, and the potential for healthcare facilities to get appropriately compensated for the treatments they provide.
Those aren’t the only problems, though. Poor documentation practices can also lead to serious legal issues. For example, failing to provide complete (and accurate) documentation can result in being named in medical malpractice lawsuits if or when they occur. That kind of lawsuit can take many years to resolve, and in some cases, it can lead to serious questions about a nurse’s proficiency.
Tips to Improve the Documentation Process
The best way to avoid problems with documentation is to improve the documentation process and ensure it’s done correctly every time.
Get to Know the Nurse Practice Act
The first thing you can do to improve the documentation process is to download and read through the entire nurse practice act. This act is available as a state-by-state download, so check the National Council of State Boards of Nursing to find yours.
The documentation goes over important information such as your responsibilities and how you can provide the right kind of care for your patients. By reviewing this documentation, you’ll put yourself in a better position to avoid legal issues and protect your license by providing the best possible care to anyone you work with.
Refresh Your Skills
Another way to improve the documentation process is to ensure you’re refreshing your skills regularly. It’s not a bad idea to take a refresher course on how to create the best documentation of your workflows. Additionally, since you will need continuing education for your license, it just makes sense to add a refresher on documenting patients’ care to that educational lineup.
Electronic health record (EHR) systems have become a fundamental tool in modern healthcare, streamlining patient care and improving overall efficiency within facilities. Nurses will need to maintain their experience working in these systems to ensure accurate and efficient documentation.
Take Advantage of Documentation Resources
There are many resources that can help nurses learn to document their interactions with patients and during their shifts correctly. One helpful resource is the National Council of State Boards of Nursing’s brochure, “State and Territorial Boards of Nursing: What Every Nurse Needs to Know.”
This brochure goes over the reason there are Boards of Nursing and provides you with information such as what happens if the NPA is violated and the processes for filing complaints against nurses. It also walks you through what happens while a complaint is investigated, if you ever find yourself on the wrong end of a patient’s concerns.
Build Your Career with SHC
Good documentation is a necessary part of building your nursing career and protecting your licensing. With the right documentation, nurses can show effective communication and even more importantly, demonstrate commitment to quality patient care.
At Supplemental Health Care, we’re here to help you find a nursing role where you can provide patients with the care they need and you can grow. Search our list of jobs now to find your next assignment or contact our recruiting team to learn more about working with SHC.
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