After you have completed a few tasks, take a moment to chart. Be sure to include all pertinent data regarding complaints such as pain or nausea, how well someone tolerated a procedure, the size of the wound, color of any drainage, odors, and signs and symptoms of infection or healing. If you did any patient or family teaching, document the outcome and note what they need to do or learn next.

Remember you are discharge planning from the moment of admission, so you need to help the patient and family assume responsibility for the patient's care after release. The patient and his family might need help when they first get home, but you have begun the process toward making them independent. Whatever you can include about what the patient or family member learned or demonstrated will be most helpful to the discharge planner as well as the physician.

If you document as you go along, you'll find yourself ready to go home at the end of the day without having to spend another hour doing paperwork. Things will be fresh in your mind and you'll be far less likely to forget some all-important information than if you let the day get away from you. If you do forget something, be sure that you know how to add an addendum to your notes and how to document an event out of order.

Some nurses use sticky notes to write things down that they need to relay to the physician or other team members such as the discharge planner or perhaps a physical therapist. This way they can leave the note in the chart for that person and not have to rewrite it later. These notes can be very helpful and can save a lot of time.

One habit to avoid is using multitudes of small pieces of paper to write your notes on. Some nurses routinely grab paper towels to scribble on. This might work in an emergency, but is not a good habit to learn. Keep your notebook in your pocket or buy a PDA. The less time you have to spend trying to piece together a multitude of small pieces of paper or to dig through the trash to find those wound measurements the doctor asked for, the more time you'll have for your regular work. And you'll once again reduce the opportunities for sabotaging your day and finding yourself out of control and overwhelmed.

Remember always that the medical record is a legal document. It is your proof that you did something. You want the chart to reflect the quality care you have given and you want to protect your nursing license at all times. Accuracy is a vital element. You are providing an annotation of the patient's experience for all other health care team members to refer to in analyzing the patient's progress and outcomes.

Many people feel that the paperwork is an annoyance and insignificant to patient care. The truth is that documentation is one of the most effective means of interdisciplinary communication that the health care delivery system has to offer. In the absence of face-to-face opportunities, the written record affords us perhaps the only form of communication and evidence of the care delivered and the patient's response/outcome.

Documentation does not have to be a dissertation or a thesis, but it needs to include enough information to paint a clear portrait of the events of the shift. Any nurse following you should be able to read your documentation and have an understanding of the patient's condition, as well as the care you provided and how it affected the day's outcomes for that patient.