The Importance of Writing It Down
Never count on your memory for complete accuracy. Write things down. Don't keep information in your head. Communicate and share what you know. The possibility always exists that you could be called away from your unit and if you haven't communicated with others, tasks could be mistakenly repeated or omitted.
The patient's safety, well-being, and positive outcomes are your prime objective. Your best proof of what you did and the patient's outcome is in your documentation. You may one day need your documentation to be detailed enough for you to testify without a shadow of your own doubt that everything written is exactly as it happened. You won't be given a chance to supplement or to add your own comments later on. The documentation has to stand on its own.
Documentation TechnologyA PDA may afford you the best possible solution. You can set up a new screen for each of your patients in the most basic of notepad software that comes built-in with your PDA. Or you can choose from an elaborate number of other software choices that can include customizable forms to write your notes in.
Your facility may even have the capability of using software that can be synchronized with the main systems to upload from your PDA directly into the hospital's records. This is becoming more commonplace especially where computerized record keeping has been utilized for some time.
Some wireless, paperless systems have the capability of documenting at the bedside, which affords you the opportunity to document immediately. Without this type of situation, your best means of presenting the most accurate documentation is by taking and using notes and then documenting from them as soon as you can.
The advantage of a PDA is that you can protect your files with a password. Even if you misplace your PDA and someone picks it up, they won't have immediate access to confidential information. However, you will need to use some type of system to maintain confidentiality in the event that you neglect to delete your notes before you leave for the day with the PDA in your pocket.
Organizing Your NotesWhatever system you choose, the more you can customize your work for yourself the more time you can save on the other end. This will ensure that your documentation will be more accurate and timely as well. Don't reinvent the wheel; ask your coworkers if they have something similar that works for them. Perhaps you can brainstorm and come up with something that you could share and duplicate.
You could devise your own system of identifying patients while keeping a large variety of notes on an organized worksheet. A simple means is numbering your patients one through five or six, in order of your assignment.
Other considerations for your note-taking system include a means to keep the information confidential. You don't want to drop scraps of paper from your pocket in the hospital cafeteria with identifying information on them along with current vital signs or medication notes. You obviously don't want to lose them and you certainly don't need others finding them.
Another purpose for your notes includes making lists of the following:
Information you need to share with other team members about a patient.
Things you need to research on your own for your benefit such as a new diagnosis.
Meds that are new to you and you need to look up today.
Resources you need to check on for patient teaching.
Positive things that happened today.
Throughout your career, you should always be on the lookout for new ways to help you manage your time. Time is a precious commodity and once it's gone, you cannot get it back. Use it wisely and you will appreciate having more time to spend with your patients.
