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Nurse Notes: Top Tips for Avoiding Errors
Did you know the payout for medical malpractice lawsuits can be as high as over $1,000,000, depending on the damage? Making poor records of what a patient reports or what medicine is being administered to a patient can lead to malpractice liability.
That’s why having the world’s most perfect nurse notes is essential. All you could do to get better in the past was try harder to be accurate, but technology can help you out in the 21st century. Check out some innovative ways of avoiding the most common note-related medical errors.
Bad Handwriting
Ancient problems require (somewhat) ancient solutions. We don’t practice writing by hand much anymore, but most hospitals still use a lot of handwritten nursing documentation. There’s no app or program to tidy up handwriting; it requires practice.
However, there is a way to use technology to train yourself to write more legibly (if this is your issue). Download an alphabet in a “font” that you like and practice journaling in that font for 15 minutes daily. Within a few weeks, your handwriting will resemble a letter between 1800s royalty.
Incomplete or Missing Forms
Missing names, dates, times, signatures, medications, symptoms, or even whole forms can have awful medical and clerical implications. Unfortunately, this doesn’t mean hospitals will try to simplify this problem from their side.
Having a smart checklist app for nurses can help beat this problem. You can pre-program the app with checklists you run through each time you deal with a patient. This reduces medical errors the same way it reduced pilot errors when airlines implemented something similar.
However, if you’re more old-school, being super organized also solves this problem. Get some filing tabs from TabShop and arrange your nursing documentation in a standardized way. This way, your brain runs through the checklist whenever you deal with the file.
Subjective Nursing Notes
Using subjective or degrading information like “irritating” or “rude” to describe a patient interaction can cause big problems. Firstly, doctors have no idea what to do with this information. Everyone has different perceptions, which may skew the doctor’s opinion of the patient or you.
Secondly, if something terrible happens to the patient, the malpractice lawyer will request the medical records. Unprofessional information can be turned into damning evidence by a good lawyer.
Having a meditation or calming app is an excellent answer to this problem. It’s easier to find capacity for difficult patients when calm and centered.
Nurse Notes: Become the World’s Best Nurse
Much of a nursing job comes down to your ability to capture information. Producing excellent charts and medication instructions almost guarantees happy and healthy patients.
Practice writing nurse notes so that any information you fill out comes out clearly and neatly. Be sure to stay on top of your documents by staying organized. Using an app or filing system both work well.
It’s also vital that you remain professional. Meditation and other lifestyle hacks can help you stay calm even if you have a demanding patient. Learn more ways of upgrading your lifestyle by visiting our blog today.
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