Keep style and format consistent Content is archival End-User Documentation Almost every product you purchase has a written explanation of operation. Specific examples of end-user documentation are as follows:
Organized Compliant with healthcare laws and facility standards This applies to nursing documentation across every type of practice setting-from clinics, to hospitals, to nursing homes, to hospices.
Proper documentation serves many purposes for patients, physicians, nurses and other care providers, and families. Thorough, accurate documentation is important for communication and continuity of care-everyone involved in the delivery of care requires information about the patient.
Documentation is important for quality assurance-the information contained in patient charts is often used to evaluate the quality of service and the appropriateness of care delivered by nurses.
Documentation is also very important for legal reasons-patient records are frequently used as evidence in court.
Not dating, timing, and signing entries Every single entry should have the date, time, and the name of the person who entered it. On paper charts, indicate the date and time, along with your first initial, full last name, and your title RN, LPN, etc.
When your documentation continues from one page to the next, write your name on each page, along with the date and time, and indicate "continued from previous page" on all subsequent pages. Writing sloppily or illegibly This requires little explanation.
Sloppy writing can result in confusion and communication problems that, at best, can lead to inefficiencies and, at worst, could cost patients their lives. Regardless of the circumstances, you are still accountable for these oversights.
Always document omitted medications or treatments along with the reason for the omission and your signature. Leaving blanks on forms This leaves the reader wondering if care was delivered and not recorded, or not delivered at all, as in the legal case we looked at earlier.
Nurses need to draw a line through blanks that are not applicable on documentation forms, and initial them. Adding late entries Anyone who has ever tried to briefly memorize a phone number before dialing it knows that the information can slip away within seconds.
Failing to record actions taken and other information immediately or very soon after the event can lead to lost detail-especially when it comes to numbers-and ultimately errors down the line that could negatively impact the patient.
Clearly state the date and time of the late entry, indicate the actual time the care or observation occurred, and mark it as "late entry. In cases where the patient has a bad outcome, terms like these on a chart will call into question the kind of care the nurse provided.
Using inappropriate abbreviations Avoid using abbreviations that can be misinterpreted, and result in confusion and errors. Accepting incomprehensible orders Never accept questionable or incomprehensible orders.
This includes new abrasions, cuts, and pressure marks, falls, bumps, elevated temperatures, seizures, pressure ulcers, unusual behaviors, diarrhea, changes in bowel habits, changes in vital signs, etc. Entering information into the wrong chart This error can happen easily, especially with electronic records.May 11, · Different types of documentation In his guide entitled “Writing Great Documentation”, Jacob Kaplan-Moss places the different types of documentation into three categories: Tutorials: These will be the user’s first taste of a new tech tool, so it’s important that they make a good impression.
The technical writer structures the documentation so that it caters to different user tasks and meets the requirements of users with varied experience and expertise. The technical writer must be able to differentiate between the users and system administrators. Medical Errors in Nursing: Preventing Documentation Errors.
The importance of proper documentation in nursing cannot be overstated. Failure to document a patient's condition, medications administered, or anything else related to patient care can result in poor outcomes for patients, and liability issues for the facility, the physician in charge, and .
The technical writer structures the documentation so that it caters to different user tasks and meets the requirements of users with varied experience and expertise. The technical writer must be able to differentiate between the users and system administrators. Since Nursing is what I want to do I need to find literature, websites, etc to help me find some info for my memo.
Does anybody have any idea, or maybe a nurse I could chat with and interview to tell me about the different types of communication nurses do, such as prescriptions, or reports or something.
If . Different Types of Nursing Documentation Methods There are two categories of documentation methods in nursing such as documentation by inclusion and documentation by exception.