Information does no one any good if it's all stored in your head. You might be able to accurately document on each of your patients at the end of the shift, but what happens if you leave the floor for a break or a meal and haven't done any documentation? If something happens with any of your patients, the first place others are going to look for clues is in the chart. Beyond that, they're going to hunt down the person who is covering for you. If that person knows nothing, look out! Trouble is going to hit the fan!

You don't want to be the one caught watching another nurse's patients when the M.D. comes in and demands to know what is happening with his patients. Nor do you want to be left to decide if the present set of vitals represent a sudden change in condition or whether the patient has been this way for a while. Do you need to notify the M.D. or is he aware of this already? The information is useless if it isn't documented and isn't communicated to coworkers and colleagues.

You don't want to be the brunt of the missing patient situation either. For example, a patient has left the unit to visit with his young daughter in the lobby. The M.D. has authorized this, but his nurse didn't write the order for it before she left for her lunch break. The patient is with his daughter and ex-wife in the lobby when his impetuous new bride comes in and finds him missing from his bed. After searching the bathroom and other places on the unit where he might be hanging out, she is now half hysterical and making a big scene! You're covering for this nurse who actually left the facility to run an errand on her lunch break. She didn't tell you this patient had gone to the lobby, and it has only been five minutes since the nurse left on her break. She's not answering her cell phone. This could be a very long lunch break!