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The Ultimate Guide to Proper Documentation

The Ultimate Guide to Proper Documentation

Being a nurse does not only revolve around providing care and educating people about health conditions. It also involves proper documenting and charting. As a nurse, it is your primary responsibility to deliver the highest standard of care to your patient and in order to do this, you have to provide proper and accurate documentation. For beginners like you, New Lake College would like to share a few handy tips to help make your documentation task faster and easier:

  • Write it immediately
    This is the first rule you must not forget. You have to record whatever information you have gathered right away. In this way, you will not miss any essential information that aids a patient’s recovery.
  • Avoid abbreviations
    Abbreviations are strongly discouraged when writing data. This shortened terms can only stir up confusion which may lead to future medical errors. Given that, you have to write in complete words or phrases all the time.
  • Place the overall details
    This means you have to jot down your full name along with the time and date of entry on the sheet. This will allow the physicians, nurses, and other care providers to conveniently contact you in case of an emergency.
  • Use backup
    Today, electronic records are highly recommended too! With just a few clicks, you can easily update and access the patient’s medical file. So, if you want effective and efficient health documentation, never hesitate to use an electronic medical record system.

We hope that you learned something today. If you wish to get the latest updates on practical nursing and healthcare tips, you can get in touch with us by liking our official Facebook page.

Gain an edge over all your competitors when you receive professional healthcare training from the trusted school in town! For years, we have been known to be the premier provider of healthcare training programs in Hanover Park, Illinois. From basic nursing courses to EKG technician programs, we always offer a comprehensive and quality education. To know further about our wide range of programs, please do not hesitate to give us a call or drop by at our office.

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