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A person in a Massachusetts hospital may have many more interactions with nurses than with doctors during the stay. A previous blog post discussed simple ways these medical professionals can prevent harm to patients. According to Nurse Journal, another essential nursing duty is documentation in the patient’s medical record, which often informs future decisions and prevents serious or fatal medical mistakes.

Because administering medication may be one of a nurse’s primary responsibilities, it is essential to document exactly when and how much of each dose was given. If a doctor discontinues a drug, this should be recorded, too. Other items that should be added to a patient’s chart include the following:

  •          Nursing actions taken
  •          Health information
  •          Changes in the condition of the patient
  •          Health care provider’s orders for care

The journal, Nursing Made Incredibly Easy, notes that when documenting doctor’s orders, the nurse may need to include specific instructions for monitoring the patient and particular symptoms to watch for, such as fever, abnormal blood pressure readings, heart rate and irregular rhythms. Nurses should also provide a report to the nurse manager of any adverse events caused by medication, devices, care or lack of care.

Not only is the documentation needed by doctors, it is essential for others who provide care. As nurses rotate through shift changes, patient information will be passed along. A collaborative environment may help team members maintain open lines of communication when clarification is needed.

When it is time to for patients to be discharged, they need to know details about their recovery, such as limited activities, medical device directions and medications. The nurse should document the instruction the patient and any caregivers receive, and their comprehension of the information.