It is not only medical notes that are important; well-written nursing records will provide qualitative comment on treatment outcomes. Contributor Information, sue Stevens, Former Nurse Advisor, Community Eye Health Journal, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
In short, the patient's nursing record provides a correct account of the treatment and care given and allows for good communication between you and your colleagues in the eye care team. Do not perform charting in advance, and check institutional guidelines for the use of acronyms. Learn more about Business Communications. According to the law in many countries, if care or treatment due to a patient is not recorded, it can be assumed that it has not happened. Poor record keeping can therefore mean you are found negligent, even if you are sure you provided the correct care - and this may cause you to lose your right to practise. Re: Writing Nursing Notes, get into the habit of writing each note the exact same way. Start from the head (neuro) and work your way down. When in doubt, chart about it.
Ensure a supply of continuation sheets is available. Date and sign each entry, giving your full name. Give the time, using the 24-hour clock system. For example, write 14:00 instead of 2 pm.
Soap notes must be timely and accurate, states AllNurses. Never document care before it is provided or include care provided by other staff. Complete all areas of the chart. Describe patients' pain only if there was an intervention.