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The duty of taking care of patients can be a daunting one especially in a busy hospital where there are very many patients. All these patients come with different issues which have to be treated differently. This is why nursing notes are important. Nursing documentation is composed of planning, assessment http://www.patriotsfansproshop.com/Patr … l?cat=1411 , implementation and evaluation. Every nurse has to give documentation as to the care given to a given patient; how they planned it, decisions they made, the kind of care they gave and whatever information they shared either with the patient or other departments.
It is a requirement by law that the nurses keep a clear record of a patient’s information. This is the only way a nurse as well as any other medical practitioner can be sure of what they are dealing with in case of a given patient. Clear taking of nursing notes is thus mandatory.
Hereunder we discuss the essentials of good recordkeeping in line with nursing:
• Legible handwriting
• Entries should be signed, dated and timed. It is wise to add the author’s name as well as job title just alongside the first entry.
• There should be a specific order of entering records preferably chronological.
• Clarity and accuracy of the records must be considered
• Facts should be given priority as opposed to irrelevant speculation http://www.patriotsfansproshop.com/Patr … l?cat=1448 , jargon or unnecessary abbreviations.
• When recording information a good nurse must always use professional judgement as to what to include and exclude.
• Reviews and assessments must be well recorded by clinicians as future evidence in case further care may be needed.
• Records should identify any risks or problems that have occurred and show the action taken to deal with them
• Security of the records should be taken into consideration. All originals should not be tampered with or destroyed.
• In a situation where you are compelled to alter records, it is prudent to clearly amend the original documentation and clearly indicate the name, job title, signature as well as the date of the person carrying out the amendment.
• In some cases http://www.patriotsfansproshop.com/Patr … l?cat=1451 , you may have to involve the patient and the language used must be clearly understandable.
• In case you scan or photocopy records, the same must be legible.
• Nurses should not use coded expressions of sarcasm or humorous abbreviations to describe the people in your care
• When a patient comes into your care, as a nurse it is inappropriate to use humorous abbreviations or sarcastic coded expressions when describing them.
• Always give true records.

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