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Charting Nurses Notes. While time consuming good charting is essential to providing top notch patient care. A short nursing documentation audit tool. Federal state and institutional regulations require that nursing notes follow broad guidelines to determine if a nurse s action was reasonable and prudent. A neat and clean documentation is praiseworthy and a little positive commendation is also food for the soul and the ego and for your performance of course.
While time consuming good charting is essential to providing top notch patient care. Nurses are known for saying if you don t chart it it didn t happen. Johnson m jefferies d langdon r. A neat and clean documentation is praiseworthy and a little positive commendation is also food for the soul and the ego and for your performance of course. Remember each entry should include your full name the date and the time of the report as well. Fill out the notes within 24 hours of supervising the patient s care.
Think of your ink.
A meta study of the essentials of quality nursing documentation. Key points when taking a nursing note. Journal of nursing management 18 7 832 845. The nursing and midwifery content audit tool nmcat. And because your charting notes are legal papers use these ink colors and nothing else. On that note any situation in which the chart will need to be erased or altered should be avoided.