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Principles of Recording in Nursing

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  • 0:01 Record Keeping
  • 0:59 Importance
  • 1:44 Principles
  • 4:28 Lesson Summary
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Lesson Transcript
Instructor: Rebecca Gillaspy

Dr. Gillaspy has taught health science at University of Phoenix and Ashford University and has a degree from Palmer College of Chiropractic.

Proper record keeping is an important aspect of patient care. A patient record is a permanent document that chronicles a patient's care history. Learn why record keeping is important and the principles of record keeping in the nursing profession.

Record Keeping

Let's say you love to cook. One day you come up with a great new way to make spaghetti sauce. You add all the right spices in all the right amounts, and the result is delicious. But let's say you forgot to write down the recipe. Without a record of how you made your fabulous sauce, you'll never be able to make it again. Just like a cook needs to keep detailed records about ingredients, a nurse needs to keep detailed records of patients.

Record keeping is the act of organizing and documenting information relevant to a patient's treatment. Good patient records include well-documented details about patient care, and the patient's response to that care. In this lesson, you'll learn why proper record keeping is important and principles that must be followed to ensure proper record keeping.

Importance

A patient record is a permanent documentation of a patient's care by a health care provider. While it might feel as if a nurse is interrupting treatment to write down notes, patient records are vitally important to the continuing care of a patient. Consider this: a nurse may encounter 20 different patients in a day. It's impossible to remember details about each of these patient encounters.

Nurses must learn the principles of good record keeping, because these records serve as a history of client care, reveal patterns in a patient's progress, guide future care decisions, support financial billing and may even be used as evidence if legal issues arise.

Principles

Do you remember when we talked about the importance of writing down the recipe for your delicious spaghetti sauce? Well, let's say you did remember to write down the ingredients. However, the next time you pulled out the recipe it was so full of eraser marks, confusing abbreviations and illegible writing that you couldn't follow it. Like a recipe, a patient's records must be complete and written clearly to be useful.

There are general principles that nurses must follow to ensure the records do their job. Records should be written as soon as possible after a patient encounter. This quick action makes it more likely that important details aren't forgotten. Of course, taking notes ASAP doesn't mean they should be rushed. Take enough time to ensure that all notes are recorded neatly. Patient records must be clear and legible.

If you're not happy with the clarity of a note you make, remember that records should never be altered or destroyed without proper authority. If you do something wrong, don't erase mistakes, instead draw a line through the mistake, and then sign and date the correction.

The records need to include notes on care that was given, any problems that arose and actions taken to deal with the problem. You should also document if a patient refuses a treatment. For example, a patient complains that the medication they were given on the last visit made them feel nauseated, and they don't wish to continue that treatment. The nurse should record the medication and the patient complaint, to alert the doctor and guide future prescriptions.

While it may feel tedious, each patient record needs to include the date, time and a signature. These elements help develop a timeline for patient progress, and could prove vital if the patient notes are needed in a legal case. It also helps to use standard terminology and abbreviations, so there's no confusion amongst professionals that might need to review a patient's records.

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