Nursing documentation is in deed a headache. As per taught in school
" what is NOT documentated is NOT considered done in the eye of laws."
It's perfectly fine to qoute exactly what the Dr, Patient or relatives say however,
all these depends on circumstances too.
I usually quote when it is gona be a potential complain ot affects the patient's health care professionals
or relatives safety. This is to protect not just your patients but your license as a nurse..
Alot of time U nvr know when things will happen and u may be called to the court after a few years
And your documentations will savw you alot of trouble.... i sahre one incident with you.
I Had a patient who needs to be transferred to the other ward due to discipline over flow.
When I was at the receiving ward, my collegue called me and told me that the lab staff wana speak to me.
I was informed by the lab staff that patient is MRSA +ve for blood culture. I informed the the receiving nurse
about the results and also told her to informed to informed the team drs about it as the team drs were in her ward
making rounds then. I documentated what I done. 3 weeks later, I was on annual leave and when I came bk,
I was told by my NM that the patient whom I transferred had been disharged without treatment and was readmitted one week later and passed away in ICU for sepsis. When they tracked back the notes...
Cos it was considered a negligence event.... So My documentations had saved me to go through the interrogations by the onvestigating board.
It's better to write more then not write at all... U need to be factual and summarise the key points so that it will not become a essay..
hope this helps.