NURSING DOCUMENTATION TIPS (2018)
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- เผยแพร่เมื่อ 6 ก.พ. 2025
- NURSING DOCUMENTATION TIPS
Nursing documentation is a HUGE deal in nursing school. I know you're worried about if you're doing it wrong or not, and honestly, you might be making some critical nursing documentation mistakes.
In this video, I'll walk you through 3 nursing documentation tips that you MUST know about in nursing school. These 3 tips are some common nursing documentation errors that I've seen nursing students make, and I don't want you to be one of them.
So, during your nursing school clinicals, make sure you follow these 3 nurse charting rules:
1. ONLY use abbreviations or acronyms that are approved by your nursing school clinical facility. Your nursing documentation is a legal document, and MUST be thorough and clear enough to hold up in a court of law.
2. Follow a pattern with your documentation. Always document the same way every time so you don't forget anything in your nursing documentation.
3. Document right away, as you go. Avoid medication, treatment, and nurse documentation errors when you do your patient charting as you go.
By following these critical nursing documentation tips, you can save yourself a huge headache later by knowing your nursing documentation is thorough and accurate.
Make sure to download your FREE nursing abbreviations cheat sheet right here: nursingsos.lpa...
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LEGAL DISCLAIMER:
These videos are intended for entertainment purposes only. Although we strive for 100% accuracy in all of our videos, errors may occur. Never treat a patient or make a nursing or medical decision based on the information provided on this channel or in our videos. Never practice nursing or medicine unless you have a proper license to do so.
Great advice, Documentation is very important, I don’t like abbreviations,I will definitely write out everything fully. I feel like abbreviations could be misunderstood sometimes, I think it’s best to just write a full description without abbreviations. Thank you for your videos, keep them coming.. 🙏🏽
YESSSS!! I totally agree. Leave no room for interpretation.
Same
I love your enthusiasm for teaching and the way you break the information down to make it understandable! 👍❤️
Thank you for letting us know you loved this video, Mar D. 😊 Our favorite part of our day is hearing about how our resources have helped YOU! Your support means the world to us. 😁
LOVE, the energy! Such a great video! Thank you!
Woohoo! Thanks for letting us know you loved the video, Nina Rosa! We're so happy to hear that! :)
Thank you, very helpful. Specially with the insulin incidents, because it happens regularly.
Luel DeKuek, so happy this helped you! Your support means the world to us!
I love your videos. They have been so helpful to me as a brand new nursing student. Than you for all the help!!!!
So happy to hear this video was helpful for you, Darlene Murphy! 😊 We LOVE hearing how our resources helped you feel more confident in your knowledge! Hope you have a fantastic day, Darlene Murphy. 😀
Please do a video on pathophysiology of anaphylaxis and hypervolemia! your videos are super helpful!
I'm so glad you love our videos! I'll definitely add those to the list. :)
Your the best teacher
So happy to hear this video was helpful for you, Katherine Zinn - Ficken! 😊 We LOVE hearing how our resources helped you feel more confident in your knowledge! Hope you have a fantastic day, Katherine Zinn - Ficken. 😀
Thanks very much for this lovely tips
So happy to hear this video was helpful for you, Clara Azike! You will do GREAT! Thank you for being here, your support means the world to us. 😊
Can any nurse within a healthcare system view my records even if I’m not their patient? I’m asking because I know people who work for the same hospital I’ll be visiting but I don’t want people know seeing my stuff?
For example I’ll be receiving prenatal care at a hospital. I know people who would possibly want to nose through my information. I won’t be visiting their clinic but it’s all connected. Can they see my records?
Hey Holly! Our resources are to help nursing students through nursing school. We cannot give out any medical advice, or speak to specific facilities and their policies. We always recommend if you have any medical specific questions they are best addressed with your healthcare provider. Thank you for understanding. Hope you have a great day! 😊
Wow! AWESOME!
Thank you for letting us know you loved this video, Joyleen Strozier. 😊 Our favorite part of our day is hearing about how our resources have helped YOU! Your support means the world to us. 😁
@@NursingSOS Your welcome!
Can I get the sheet, I’m unable to download it , the link doesn’t work !
SaRa ؛، so sorry about that! You can find that cheat sheet, and so many more, right here: nursingschoolofsuccess.com/signup
Thank you, heaps helpful
Henrique Wagner yay! We are so happy to hear that this video helped you understand better. 😊 You will do GREAT, friend!
All of the energy. All of it. LOVE 🌸🌸🌸
Thank you for letting us know you loved this video, Julia Mc. 😊 Our favorite part of our day is hearing about how our resources have helped YOU! Your support means the world to us. 😁
I love your charisma,so helpful
Thanks for being here, Rozay Linda!
I mean or the situation when you take vitals on all your patients and then someone puts your vitals sheet in the shredder thinking it is old.
Alainna Griffiths, Ugh!!!!! losing that brain sheet, or the alcohol pad you've written the labs down on or vitals on is the worst!!! You're right! Thanks for being here, friend!! :)
This is so helpful! ❤️
Woohoo! Thanks for letting us know you loved the video, Nurse Nzi! We're so happy to hear that! :)
LOVE!!! ♥️
Love it! thank you
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Love this video. ❤️
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so helpful
Thanks for being here, Information center! Glad this video helped you!
cool video but we need examples x
Thanks for your feedback, Maryem Hashimi! We'll add that to the list for future videos. :)
Love ❤
LOVE!!!
Yay!! I'm so happy you loved this video, Lydia! Thanks for being here :)
Always Bulletproof all your charts. Just write everything down as if your life depended on it! You'll be compensated dearly when you finish your nursing school and become an actual nurse. Act like abbreviations and any other writing shortcut are illegal. Leave that sh*t to the friggin' Doctors. lol 😜
You are right that you should write everything down, thanks for your input! And thanks for being here, cepedaruben1!
Lovely
Thanks for letting us know you loved this video, Bernard T! Thank you for being here😊 Your support means the world to us!
love...espicially the abbreviation part
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Love!
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❤❤❤
I'm so glad it helped!
LOVE!
Thanks for letting us know you loved this video on documentation mistakes, Mechell Simms! Glad to hear it and your support means the world to us! :)
Hy
Thank you for being here, Prince Isreal! Your support means the WORLD to us! Have a fantastic day! 😊
Love
Woop Woop! I'm so happy to hear this video helped you out, friend!! :)
Sure will thanks for another awesome videos keep up the wonderful work !
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YAY! I'm so glad you loved it!! :)
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@@NursingSOS Thank you !
You're welcome, Ethan Parker!! Thanks again for the support! Have an amazing week! :
Love!
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Yay!! Thanks for letting me know you loved it!! :)
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