Topics About 'Documentation'.

On my drive home 45 minutes away from the hospital, I realized I forgot to finish my wound documentation. I did the wound change, I took a photo of the wound like the order says and it is in the MAR as proof that I did the wound care. I only charted ...

The amount of time documenting and the erroneous ridiculous repetitiveness of one important finding can take 5-10 minutes to document. Dare you say the patient had a headache a week ago or right leg pain and the documentation will ask you 10 questio...

We have about 45% of our kids on campus, and most of my high needs kids are doing virtual learning. I was super busy with paperwork and beginning of the year stuff at first, but now that I've finished all that, I find myself wondering what to do nex...

Though it can vary by state, typically the statute of limitations to file a medical malpractice lawsuit is two to three years. Though most claims are settled out of court, if it does go to trial, the average malpractice case takes 3-5 years to resolv...

It's never-ending, the paperwork. Nurses spend a LOT of time charting important details about their patients. Many times, these details can mean life or death. And, the documentation must be legible, complete, and accurate. How do you balance patient...

I never planned to become an expert nurse witness for medical cases. I didn't go to any class to do this. I'm a pediatric ER nurse and a clinical instructor. However due to my expertise in pediatric triage and assessment, identified through some of m...

The long term care industry (a.k.a. nursing home industry) employs a large share of new and experienced nurses in the United States. Furthermore, the number of nurses who secure employment in this specialty is projected to increase in the next ten ye...

Working in Remote AreasWhile working for Health & Welfare Canada as a community health nurse, I received advanced training for outpost nursing at Dalhousie University in Halifax, Nova Scotia. In our training, we were taught the cardinal signs for...

I have worked at my outpatient surgery unit for 8 years and have never had any type of write up. Yesterday my manager called me in to give me 2 page write up with several incidents starting April 23rd! This document contained many outright lies and s...

Documentation and the average nurse is a hot topic, so you have to start as you mean to go on! Documentation in nursing varies a great deal, what you should document, what you do document and what you don't document. Documentation is a minefield. We ...

Is there a website or books to help me about nursing procedures documentation? I'm having a hard time documenting the procedures that I have done.

The medical record is a permanent collection of legal documents that should supply an all-encompassing, accurate report concerning a patient's health condition. Physicians, nurses, social workers, dieticians, mid-level providers and other members of ...

I have a question for those that run NXStage CRRT regarding documentation. I’ve ran CRRT with nxstage for about 8 Years, at this new facility how I was taught to document makes absolutely zero sense to me. I reached out to the educator and asked how ...

I'm a first year nursing student and I have a learning issue that I need to get some information on. I'm trying to find out what your employers policy on documenting falls are and who gets notified. I am mainly just trying to compare the differe...

I am wondering if other nurses write change of shift nurse’s notes every shift. Example: Bedside report received from ____. Then insert here current patient status or whatever smart phrase you have come up with for your change of shift note. ...

I just awoke and opened my eyes for only a split second to barely be able to make out the face of my recovery nurse. I feel so weak and powerless right now, the anesthesia must not have worn off yet. She just asked me if I want to see the gallstones ...

I had a patient who was type 1 diabetic. Patient was on insulin. Blood sugars were elevated. MD is saying I didn’t administer insulin and the blood sugars were never treated. I have documentation in the MAR that insulin was given several times. ...

One of my fellow nurses- let's call her Jane- was overheard complaining loudly this morning. She had received feedback from a physician that one of her chart notes was "unacceptable." She went on to say that she didn't understand why her note was una...