Nursing Notes/ Documentation/ Propose/ Do, Don't

2. NURSING NOTES
GM SIDDIQUI
Clinical Instructor
The Kidney Center PGTI
NURSING
DOCUMENTATION

3. Documentation within a patient medical record is
a vital aspect of nursing care or practice .

4. PURPOSE
 The purpose of the medical
record is to provide a clear
and accurate picture of the
patient while under the care
of the healthcare team
(Campos, 2009).
 Communication
 Legal Documentation
 Nursing Audit
 Educational

5. Do's and Don'ts of Nursing
Documentation

6. Do's
 Patient Name
 Dr’s Name
 Date & Time
 Legibility
 Use approved abbreviations
 Name/Signature/Code
 Patient Care
 Accurately document a patient’s refusal
Note :
Noting each phone call to a physician, including the
exact time, message, and response

7. Don’ts
 Don’t chart a Symptoms (e.g. Pain ) without also
charting what you did about it.
 Don't use shorthand or abbreviations that aren't
widely accepted.
 Don’t document for another health care provider
or sign off on another staff notes
 Don’t correct or destroy a colleague’s notes.
 Never document medications as given before
you administer them.

16. Remember the old saying,
“if it wasn’t documented, it
wasn’t done