Taking notes in professional practice, things that need mentions how to make it sound professional, clear and concise. Notes must be eligible and full of professional terms and key information easily conveyed.
Ensure your writing is clear and legible
Illegible handwriting can lead to a patient receiving the wrong medication or an incorrect dosage of the right medication. This can have serious, or even fatal, consequences.
Note all communication
Jot down everything important you hear regarding a patient’s health during conversations with family members, doctors and other nurses. This will ensure all available information on the patient has been charted. Always designate communication with quotation marks.
Write as often as you can
Write your notes within 24 hours after supervising the patient’s care. Writing down your observations and noting care given must be done while it is fresh in your memory, so no faulty information is passed along.
Effective records ensures that information is properly managed and is available whenever and wherever there is a justified need for that information to:
- support patient / client care and continuity of care
- support service provision
- support day-to-day business which underpins the delivery of care
- support evidence-based clinical practice
- support sound administrative and managerial decision making, as part of the knowledge base for DoH, HSC and Public Safety services
- meet legal requirements, including requests from the public under subject access provisions of the DPA 1998, FOI Act 2000 or EIR 2004
- assist clinical/professional and other types of audits
- support improvements in clinical/professional and service effectiveness through research and also to support archival functions by taking account of the historical importance of material and the needs of future research
- support choice and control of patients and clients over treatment and services
The increasing shift towards electronic records will transform the way health and social care information is managed. In the mixed economy of paper and electronic records it is essential that they are managed consistently to ensure that a complete record is available at the point of need.
Richard Branson, wrote,
“If you don’t write your ideas down, they could leave your head before you even leave the room.”