Effective documentation is a tool for giving high-quality patient care, and poor documentation can cause a whole host of problems for the patient, the healthcare team, the facility, and you . You are unsure exactly what information to document. You waste time trying to figure out what to include in a quality nursing note. Your patient gets hurt because you did not record his allergies on the proper form. You overlook documenting a vital piece of information, and you end up in court.
Documentation is easy to hate, time-consuming, and hard to complete.
But good documentation can save lives, time, and money. And it is at the core of who you are as a nurse. It discusses many of the national standards and practical pointers to comply with these standards and is an excellent resource. Order Notes on Nursing Notes Notes on Nursing Notes is a companion to Documentation Skills for Quality Patient Care. A brand-new documentation tool, Notes is designed as a quick reference for use at the bedside or in the charting area to improve and speed documentation.