NRSG-7065 Lecture : Documentation
Document Summary
Documentation within the nursing practice is vital to the upkeep of fundamental patient care. In order to optimize client care, it is crucial for all nursing documentations to be clear and concise. However documentation and reporting practices differ among institutions and jurisdictions and are influenced by ethical, legal, medical, and agency guidelines (astle & Duggleby, 2019) considering proper documentations are written following certain guidelines, this essay will focus on analyzing three problematic nursing patient notes. In relation to the notes, the first one has unclear abbreviations, the second one is disorganized, and the third one includes personal opinions when it should simply include the facts. To start off, the first patient note differs from illustrating proper documentation since it includes multiple unclear abbreviations. The use of unofficial abbreviations are advised against to avoid confusion and to prevent avoidable errors in the workplace. In this documentation, the reader must predict the meanings of each abbreviation used.
