Nursing Practice Tip: Documentation “Never” Events!!

I think we’d all like our roles as nurses a whole lot better if we didn’t have to document. I hear nurses say all the time that they spend more time DOCUMENTING than taking care of patients. And sometimes, I agree.

But documentation is an important part of what we do. Why? Well, documentation helps providers identify problems and make appropriate treatment decisions; allows you to take credit for the work you do; ensures that you’re practicing according to standards of care; and helps your organization get the maximum reimbursement for your hard work!!

However, documentation can also be used against a nurse – especially when patients have bad outcomes.

AVOIDING LANDMINES: SURVIVAL TIPS FOR NEW NURSES

LANDMINES!!!

New nurses spend the majority of their time trying to survive orientation! However, you may be unaware of the hidden land mines that exist in healthcare. Knowing these land mines ahead of time and learning the strategies to avoid stepping on them are as important if not more important than learning how to complete the OR checklist, document or even pass your meds on time.

To help new nurses successfully transition into professional practice, I’ve written an eBook titled, “Survive and Thrive: A guide for new nurse success.” I’ve devoted one chapter to helping new nurses avoid the landmines that they don’t teach you about in nursing school but could make or break your career.

The following represents a sampling of some of the landmines I include in the eBook:

TIPS FOR NEW NURSES: DEATH BY CHARTING

Nurses frequently complain that they spend more time charting than they do caring for patients. And, they’re sometimes right but it doesn’t have to be that way.  Patient care is important but so is the documentation of that care.  Why? Patient documentation is crucial to discover assessment trends, determine patients’ responses to treatments, and documentation provides a means for reimbursement. Documentation also protects nurses when bad things happen to patients (will blog about that later!!). However, it can be frustrating when you have to choose documentation over “caring” for your patient.