During the busy work schedule while taking care of so many patients, keeping record of every patient can really be a daunting task. It can distract you from the real work for which you have been hired. However, keeping record of every patient is also equally important as you cannot afford to remember every detail about the patient. Without maintaining proper record about every patient, you cannot hand over your duty to your next team of nurses.
The quality of nursing service is very much dependent on how well the records have been maintained about each patient in the hospital. Any poorly written record will not only reflect the quality of work of the nurse, but it can also be fatal for a critical patient.
Besides that, there is a legal significance about the nursing records. In case any patient ever complains about the treatment then the nursing record is the only proof that is legally valid. If proper record does not exist then legally it is considered that the treatment has not happened at all. You may click on this website to learn more about various aspects of health records.
How to maintain a good nursing record
The record must be current, accurate, comprehensive, objective but concise during the stay of the patient in the hospital. Records used to be handwritten traditionally however nowadays electronic recording is introduced. Following procedures are adopted for creating any nursing record.
- Standardized forms are used where nurses are expected to make necessary entry about each of the patient. As and when any nursing service is provided it must be properly entered on the form and must be documented. The record must include planning, assessment, evaluation and implementation records about various nursing care.
- Every record must be identifiable with patient’s name, address, age, details about next of kin etc. If any sheet is further attached with the record then it must also contain all these details.
- Make sure that the format for the continuation sheet must be same.
- There must be date and signature available for every entry so that it can be identified who has recorded the details. Time of the record should also be mentioned in 24-hour format.
- Never write with pencil but prefer dark black ink for entry and the record should not be exposed to sunlight so that the record may not get faded or erased.
- When the patient is admitted then there must be a record about his or her pulse rate, blood pressure, temperature, respiration or any other records necessary as per the condition of the patient.
- The problem and diagnosis also must be available together with all the medications given to the patient.
- Record all the observations as recommended to the patient by the doctor and make necessary charts if necessary.
- If the patient requires surgery then record all the checklist so that it can be reflected how the patient was prepared for surgery.
- Prepare proper discharge record when the patient leaves the hospital and what are the follow-up treatments will be needed and detail about further appointment.
Documentation in nursing helps clinics and hospitals provide the best and personalized care to their patients, and also serves as an essential growth strategy for the organizations, as it helps in maintaining their accounts and bookkeeping in the most professional way.