I'm a new nurse, still on orientation. Documentation is one of my big fears right now and I have a question about documenting conversations between yourself & a patient. Basically formatting.
Here's why: I had a pt a few weeks ago that was very non-compliant, rude, etc. He was given one more chance to change his behavior and my encounter with him, of course, was his 3rd strike. I had to document the conversation we had.
I wrote it like you would read in a novel:
I said, "Blah, blah, blah." He said, "blah, blah, blah." I did this and that, then he said, "blah blah." Etc.
I had a nurse tell me a long time ago (I was writing a witness statement & asked him to proofread) to write down all the things the pt said, like in a list, then write everything I said below that. He said that whoever was reading it would figure it out, but that just didn't make any sense to me.
So now, here I am over-thinking my documentation that probably doesn't matter this much! Lol
