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Although this may seem obvious, accuracy is crucial in all areas of medicine administration and treatment. You will be protected from being scrutinized if you accurately report sequences of events, doctor orders, and patient concerns.
Example "Did dressing changes."
This is the complete record of your dressing change for a patient. This would be a more exact version:
"Performed dressing changes, cleaned wounds with NS and gauze. Calcium alginate was applied. Covered with ABD. Secured with silk tape. The patient tolerated the procedure well.
This revision gives a clear overview of each step and explains how to use all materials. (Note that additional explanations may be required to describe the wound status, any changes, or notifications from doctors.
Try to eliminate personal feelings and opinions from any writing. You should be able to think objectively and not only record your thoughts, but also your feelings.
Example "Patient acting insane."
This statement is based on the nurse's subjective assessment of the patient's mental condition. An alternative version of this statement would be:
"Patient is pacing backwards, breathing quickly, clenching fists, and shouting 'Don’t touch me!' repeatedly.
This gives a clear picture about what happened during the incident and allows the reader to draw their own conclusions.
Keep Your Critical Audience in Mind
Auditing and litigation are part of the medical profession. This means that your writing may be scrutinized for inconsistencies and mistakes. These readers will be satisfied with your reporting and charting skills.
Examples "Did dressing changes." "Patient acting insane."
The examples given above could be used to show cause for correction, or they could be used against you in court. The phrase "Did dressing changes" does not specify any necessity for specific materials. It leaves no room for doubt about compliance with doctor-ordered treatment and may allow expert witnesses to make accusations. Without describing your actions and making quantifiable statements, writing "Patient acting insane" can lead to negligence charges. In extreme cases, either one of these situations could lead to you losing your license.
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