Best Practice Documentation for Nurses

Q:

Can you provide some information on best practice documentation for nurses when completing orders that are not performed on the date they were ordered? 

A:

This is a great question and the nurses in your clinic may also be a resource to answer your question.  While documentation may occasionally be viewed as being burdensome, we can all agree that quality documentation that is accurate, valid, and complete is an integral aspect to patient care.

Some recommendations for nursing documentation are listed below and it will be a great guide for getting started but is not an all-inclusive list.  It will depend on the nursing service provided, e.g., patient presents for lab work versus patient presents for blood pressure follow-up after recent medication changes for uncontrolled HTN.  Some best practice nursing documentation includes: 

  • Date service provided
  • The order
  • The ordering practitioner and date it was ordered,
  • The diagnosis/reason for the service
  • Nursing assessment as indicated
  • Nursing action as indicated
  • Patient instructions
  • Follow-up plans
  • Collaboration/conveyance of information to treating physician
  • Nurse’s legible signature and credentials

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