Find your better future.
Goodbye working unhappy, hello doing what you love. Trust our specialists to make your job search easy.
In the heat of an emergency or after a never ending stream of uncooperative or difficult patients, sometimes the idea of paperwork and accurate data recording is difficult for nurses to fully apply themselves to.
Yet exceptional record keeping is an essential skill that all nurses must learn and then complete perfectly on a day-to-day basis if they want to succeed and progress in the medical sector.
A patient’s medical history and progression of treatment, the amount of drugs that are accessible for use and reports on major incidents all need to be definitively documented by nurses in order for the optimal running of a ward or a care system.
Every organisation will have it’s own policies and procedures when it comes to records and requirements for nurses. Make sure to familiarise yourself with these as soon as you begin working at a new place of work or return after an extended period of absence.
In the event that a nurse presides over an incident or patient that they believe could result in a court case, it is imperative that any red flag situation is documented as quickly and in as much detail as possible. These incidents include:
In the event that you are dealing with an emergency, always take some notes on a piece of paper to remind you of important aspects that have to be remembered when a full report is written at a later stage. Such aspects can include the time of the incident, medication given or stock used, activities performed and outcomes obtained.
Remember, even if you have already manually done something for the benefit of a patient’s care or comfort, for the wider institution as a whole if it has not been written, it has not been done.
A failure to cite or document any procedure could result in hazardous or even fatal consequences for patients due to a toxic mixture or incorrect dosages of drugs.
With these points in mind, here are Search Medical’s top six tips to ensure exceptional record keeping.
Search Medical is a specialist in not only sourcing and placing nursing jobs but also guiding our workers through some of the most important issues surrounding the profession. If you have any questions regarding exceptional record keeping please contact a member of the Search Medical team in your nearest England office.
By John Murphy