Record keeping is an important part of a nurse’s job.  If records are not kept the doctor may go off of an unreliable patient history, which could lead to less than ideal treatment.  Simply put, good record keeping skills protect the patient because it allows for the highest standard of clinical care.  Good record keeping is the way that the nurse communicates with the doctor so that the doctor can provide the type of treatment that is needed, as well as detect health problems early on.

Many nurses find that record keeping is one of the most difficult parts of the job.  Many nurses just don’t feel like they have the time to keep good records so they don’t stress the importance.  Medical records need to be as accurate as possible for the protection of the patient as well as the protection of the doctor and the practice.

Nurses might learn many different techniques for record keeping that may or may not work for each individual.  Regardless of the template or model that is taught a nurse should always ensure that his or her notes are:

>> Factual
>> Consisten
>> Accurate
>> Clearly written and legible
>> Accurately dated and timed
>> Not littered with abbreviations
>> Able to identify problems of the patient and solutions
>> Provide evidence of care and information delivered to the patient

If a nurse follows these basic rules when he or she is keeping records, they will provide the doctor and the patient with everything that is needed to ensure treatment and diagnosis of any and all applicable health problems.  Record keeping is a very important part of the medical business that should never be overlooked.  Making time for record keeping at the end of each and every shift, if not more often, is one of the most important jobs a nurse will ever have in any medical setting.

Record keeping is an important part of a nurse’s job.  If records are not kept the doctor may go off of an unreliable patient history, which could lead to less than ideal treatment.  Simply put, good record keeping skills protect the patient because it allows for the highest standard of clinical care.  Good record keeping is the way that the nurse communicates with the doctor so that the doctor can provide the type of treatment that is needed, as well as detect health problems early on.

Many nurses find that record keeping is one of the most difficult parts of the job.  Many nurses just don’t feel like they have the time to keep good records so they don’t stress the importance.  Medical records need to be as accurate as possible for the protection of the patient as well as the protection of the doctor and the practice.

Nurses might learn many different techniques for record keeping that may or may not work for each individual.  Regardless of the template or model that is taught a nurse should always ensure that his or her notes are:

  1. Factual
  2. Consistent
  3. Accurate
  4. Clearly written and legible
  5. Accurately dated and timed
  6. Not littered with abbreviations
  7. Able to identify problems of the patient and solutions
  8. Provide evidence of care and information delivered to the patient

If a nurse follows these basic rules when he or she is keeping records, they will provide the doctor and the patient with everything that is needed to ensure treatment and diagnosis of any and all applicable health problems.  Record keeping is a very important part of the medical business that should never be overlooked.  Making time for record keeping at the end of each and every shift, if not more often, is one of the most important jobs a nurse will ever have in any medical setting.