Strategies Of Nursing Documentation For Promote Patient Safety

1498 Words Mar 17th, 2015 6 Pages
Strategies of Nursing Documentation to Promote Patient Safety
Introduction
Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.
Timely Documentation
Avoiding delays in documenting is one of the best ways for nurses to accurately document. It is important for nurses to set aside the time to chart as soon as they are able. It is recommended that charting should be completed,…
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