Nursing documentation includes any and all forms of documentation by a nurse or midwife recorded in a professional capacity and in relation to the provision of nursing care. This video collection explains concisely what nursing documentation is and presents 20 fundamental principles of sound nursing documentation.
The 20 fundamental principles covered are:
- Don’t erase what is recorded
- Record all relevant information
- Don’t write critical comments
- Don’t leave white space!
- Record in black or blue ink
- Clarify orders and treatment
- Chart your own nursing process
- Don’t use ambiguous statements
- Only use approved abbreviations
- Write legibly
- Use ‘late entries’ notation
- Don’t write in anticipation
- Follow organisation policies
- Record telephone calls
- Complete action and outcomes
- Use 24-hour clock
Each principle is thoroughly explained and is accompanied by examples and practical hints and tips to ensure that your documentation meets these principles, providing accurate records and effective communication.
This video is part of a series of eight on professional nursing topics. Other topics in the series cover scope of practice, role confusion, autonomy and policy, unprofessional conduct, nursing process, purpose of documentation and project management.