Proper documentation is critical to quality patient care. These records facilitate care coordination among providers.
As a nurse, your documentation should be current, accurate, organized, concise—and completed in a timely manner.
When you arrive at a facility to start your shift, you should introduce yourself and check in at the nursing station. When given your assignment, make sure you receive the login information for their electronic medical records (EMR) system to maintain proper patient documentation.
If the login isn't provided, it's your responsibility to obtain the information from the nursing supervisor or director of nursing.
Documentation Standards
Reasonable documentation standards for nurses include but are not limited to:
Nursing Assessment
Subjective data
Objective data
Assessment and plan
Implementation
Evaluation
Medication Record
Verbal orders
