Tips on proper documentation

  1. I finally set my foot in the med surg unit for to days last week...I was so nervous at first being out of nursing for a while..and this is my first exposure to a US hospital too.

    I just wanna ask for some tips about proper documentation. ..the do's and dont's. I would really appreciate it and put it to use.

    Thanks!
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  2. 9 Comments

  3. by   avolensky
    ooopppsss....I mean "two" days...sorry.
  4. by   BBFRN
    Most hospitals here have flowsheets which are pretty self-explanatory.
  5. by   baseline
    Follow the policy of your hospital and use the guidance of your preceptor.
  6. by   rn_n_02
    check you pm's!!!
  7. by   deespoohbear
    CYA!! (cover ya azz....)!!!
  8. by   passing thru
    Most hospitals have an "approved list of abbreviations" too.
    I agree with asking the preceptor how they want it done there.
  9. by   gizzrn
    there is a book called charting made easy by springhouse which shows you several forms of charting, i hope this helps
  10. by   webbiedebbie
    My hospital won't let us use cc anymore. We have to use ml. The docs are also having a hard time with this. Have to do what policy says. You should get plenty of help from your preceptor.
  11. by   NRSKarenRN
    Check out sites listed at google.com:
    http://www.google.com/search?hl=en&i...+documentation

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