I can’t imagine the level of attention to detail a traveling nurse must have, day in and day out. With little room for mistakes, a nurse must continually be alert and ready for action at any given notice and this is especially true since they are given little time to adapt to the new facilities during their various traveling assignments. How you prepare and react to any given situation is a direct reflection of the type of nurse you may be. One determining factor on just how prepared a nurse may be is in how a nurse completes their charting and documentation.
Documentation is a very important part of a nurses duties and if you keep in mind the repercussions of a poorly documented case, you will probably change the way you approach charting and everything else revolving patient care. Ultimately you must keep in mind that what you write while documenting a patients care can end up in court as proof against you and the facility in question. In some instances it is foreseeable that you may have rushed through your notes or you were interrupted during the documentation process. These are somewhat excusable, but will it be in the court of law?
In the article, “Documentation-what were you thinking?” we are given a few examples of one nurses ACTUAL notes of how they documented their care. Not being a nurse myself, these examples are truly startling and left me to wonder just how a nurse can still have a job! Here are a few samples:
- 1020: Patient to eosaphagramm????? (No idea what that means, and apparently neither did the nurse.)
- 1220: Patient suddenly reappeared in room. (Was this patient a magician?)
- 1005: Pt NPO per MD orders. Patient given PO meds with 120cc of water. Pt remains NPO. (Apparently NPO means to give orally, right?)
- Patient given 2mg Morphine IVP through that beautiful foot IV. (Hmmm… I’m sure there are technical terms being missed here somewhere!)
What you see here is from one single nurse and sheds much light on the type of nurse they may be. Not one that I think I want taking care of me. The examples above are proof to the level of care that was provided and is a direct reflection of the nurse. To a lawyer and jury it will prove the levels of care were substandard and can be all they would need to prove you were a nurse incapable of providing the best possible patient care. Not what you want on your permanent record.
In order to protect yourself from any legal battles or threats of termination I would recommend giving yourself the appropriate time to document the level of care you’ve provided for any patient in your care. A few extra minutes spent doing so can be all the difference in keeping yourself out of trouble, or worse yet, from losing your license and the job you love.
Here are a couple articles on ways to improve your charting process and how to protect yourself from errors.