You’ve been on the clinical floor for six hours and (of course) you’ve been taking great care of all your patients. The lovely woman in room 4 was brought in for a UTI three days ago and is expected to go home today.
You’ve made sure all of her paperwork is signed by the doctor. She has been educated on all of her medications and her son is on his way to pick her up. She’s good to go!
But during your afternoon rounds you walk into her room and she’s hard to wake up and mumbling words that you can’t understand. You quickly call a rapid response.
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You remember that her temperature was 37.7°C when you arrived this morning. You recheck her temperature again. It’s 39°C now. The nurse said she would give that medication to bring her fever down. You scroll through her chart but nothing was documented.
You ask the nurse, but it’s been a rough morning for her, and she doesn’t remember you telling her about this patient’s fever.
You feel your heart race in the back of your throat. This.Is.Bad.
You know you told her. But did you document that you told her?
One of the most important things you learn in nursing school is to make sure your documentation is iron clad. Each and every assessment, intervention or action you take must be documented. This includes documenting that you notified the RN about any change that occurred or any assessment data that was abnormal.
Notifying the RN and documenting that you notified them does three things:
- It protects the patient
Any status change or abnormal value might mean that additional interventions are necessary. You are ensuring that your patient receives the best care possible.
- It protects the RN. The RN is responsible for their patient’s just as much as you are. When you alert them to a patient change, you allow them to intervene and take actions to correct it. If you don’t alert them and document it, they may not find out or remember until it’s too late. The RN is depending on you to provide safe and competent care for your patients.
- It protects you; By documenting that you notified the RN, you help protect yourself from a possible legal issue.
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How to document it:
There will always be a place to document notes on a patient’s chart.
- -If your clinical site uses an electronic patient record, there might be a space for comments next to where you type in your assessment data (such as vital signs).
- -If your clinical site uses paper charts, there might be a separate “notes” page that you can use. Make sure to include the date, time and your signature along with your note.
- -If you are unsure about where to document your assessment data and notes, always check with your RN, the charge nurse or your clinical instructor.