Research centre REACH

Don’t Just Do It, Be It!

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Always document the care you deliver
Legal Requirements Your documentation must reflect the patient’s care status (condition/treatment) and include nursing interventions and outcomes of care. Documentation must demonstrate accountability of practice. Remember: The Clinical Record provides proof of the quality of care given to a patient and is admissible in court as a legal document. If it isn’t documented it didn’t happen.
The Process Clinical notes must meet the following criteria:
• they must be legible.
• they must be dated, timed and followed by author’s signature and designation.
• they must be a clearly identified signature. If your signature looks like spaghetti, print your name in brackets afterwards.
• each page must be labelled correctly,
• you must use only approved abbreviations as per hospital protocols.
Precisely document any information reported to a medical officer that relates specifically to a change in a patient’s condition. Record arrival date, time and mode of arrival. Obtain a thorough history and nursing assessment. Document any pre-existing conditions including allergies and their reactions. Thorough and appropriate documentation of haemodynamic observations including pain score.

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