The best guide to use when documenting in a patients charts is to think about the following:
- Did I perform any assessments? Yes- Document it.
- Did I observe or do anything that needs to be monitored? Yes- Document it.
- Did the patient voice any compliants/concerns? Yes- Document it.
- Did I follow-up on any existing concerns/compliants? Yes- Document it.
- Is there any information I want to pass on to the interdisciplinary team?
As far as what nurses do...there are many things that nurses do...to many to name...from legal nurse consultant to first assist in an operating room. You kind of need to narrow this question down a little. You may begin by looking at the different speciaties in the allnurse forum to get an idea of the variety of speciaties that exist for nurses.