What is good nursing documentation?
The nursing record should include assessment, planning, implementation, and evaluation of care. Ensure the record begins with an identification sheet. This contains the patient’s personal data: name, age, address, next of kin, carer, and so on. All continuation sheets must show the full name of the patient.
How do you praise a nurse?
30 Things to Say to a Nurse Right Now
- Thank you for your selfless service during these difficult times.
- You are my hero!
- We couldn’t get through this without you.
- Thank you for working so many long, hard hours to keep us safe.
- We are forever in your debt.
- Sending you a virtual hug.
- Thank you from the bottom of my heart.
What do you write on a nursing appreciation card?
Nurses Cards: What to Write in Them
- “Your passion for our patients’ health is appreciated every day.
- “Your compassion, optimism and kindness do not go unnoticed.
- “Because of you, we live in a happier, healthier world.
- “Thank you from the bottom of our hearts.”
- “Just a moment to recognize you and your hard work.
What are the principles of good documentation and record keeping?
Principles of Good Record Keeping
- Be factual, consistent and accurate;
- Be updated as soon as possible after any recordable event;
- Provide current information on the care and condition of the patient;
- Be documented clearly in such a way that the text cannot be erased;
What do you need to know about documentation in nursing?
Documentation is the primary way that we, as RN’s, demonstrate what we did, for whom, when, and with what effects. Documentation encompasses every conceivable form of recordable patient data and information, from vital signs to medication administration records to narrative nursing notes.
Which is the gold standard for nursing documentation?
Last revised in 2010, this document remains the gold standard for the basis of nursing documentation, with six essential principles serving as primary guidelines, as outlined in Table 1 (ANA, 2010a). Nurses must also acquire a keen awareness and understanding of their state’s nurse practice act to ensure documentation reflects specific state laws.
What are the Ana principles for nursing documentation?
The ANA’s Principles for Nursing Documentation (ANA, 2010a) expects that high-quality nursing documentation follows regulatory guidelines and mandates across all nursing roles and working settings.
What does electronic documentation do for a nurse?
Clinical electronic documentation will enable nurses to perform on-time charting at the patient bedside, and access patient records remotely. Some nurses might be apprehensive about changes in the electronic documentation due to a knowledge deficit in technology.