Professionalism / Documentation in Nursing - What would you have liked to know?

[Christen, ANP]

Hallo all!

I will be giving a presentation to first-semester BSN students on the importance of Documentation and Professionalism in nursing. I wanted to see if I could get some feedback. What would you have liked to have known about being a professional nurse and an excellent documentation right from the start of your nursing career?

Some points I am planning on illustrating:

Documentation

- legality

- honest documentation

- giving a good picture to other TMs (MDs, Team Leaders, etc) on what happened with a patient

- patient charges (i.e., medications)

- medicare "never events" and documentation (ex: pressure ulcer / UTI prevention techniques documented)

- objective vs subjective statements

Professionalism

- appropriate communication with other team members

- establish the importance / relationship of being a nurse and nursing being one of the most recognized "honest" professions

- Boards of Nursing

- "If it's not documented, it's not done"

- active in nursing organizations, shared governance, etc

- professionalism - providing the best, safest care for your patients (being up to date and proficient in skills, never administering a med without thinking it through, protecting your patients from harm)

I am also planning on giving some scenarios to illustrate professional / unprofessional behaviors and poor / good documentation.

What would you have liked to have known at this early stage of your career?

Thank ya!

[rachelgeorgina]

- To students? You are not anyone's friend. You are their coworker or their nurse, never their friend. That doesn't mean don't be friendly, but it means that there are big big boundaries that are really significant in nursing. Stick within them!