Useful guidelines to document the patient’s history

Documentation of a patient’s history or health record during the visit to the hospital either for out-patient treatment or for in-house treatment is one of the essential things that a qualified nurse, or a certified nursing assistant under the guidance of the registered nurse, should do as part of his or her professional duties.

Also referred to as “charting” or “nurse’s notes,” these records can be treated as legal documentation and could also be used for future requirements by other persons.

As a nurse, it is your primary responsibility to follow the simple but essential guidelines while documenting the patient’s health history.

The first and the most important thing that a CNA or the nurse should do is report only the factual things.  No illusions or presumptions should be recorded that cannot be substantiated with evidence.

The nurse should record the activities carried out on the patient, such as testing blood pressure, temperature, etc., administering medicines and dosages, and also record the outcomes of the treatment.

The nurse should also record and chart all the developments that are clinically significant, because such details might be of use for planning the treatment.

One of the essential things that a nurse should do, as part of documentation, is to clearly mention the exact site where the injection has been administered.  This is very essential because if the other nurse, who takes over on shift change, should know the exact site where the earlier injection was administered.  Without this knowledge, there is every possibility that the new nurse administers the injection at the same spot where the previous injection was administered.  This will be very painful for the patient.

At the end of his or her shift, it is the responsibility of the nurse to check and re-check more than once that all the details have been provided in the chart clearly and legibly so that the new nurse taking over the responsibility will continue the treatment without any confusion.

If, in case, you did a mistake, then you should be striking out the incorrect data, and then replacing it with the correct data.  You should also ensure that you put your initials near the incorrect data.

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