Best Practices for Documenting Patient Care as a Registered Nurse

As a Registered Nurse (RN), your primary responsibility is to provide safe, quality patient care. That care should be well-documented so that others can access accurate patient information and make informed decisions about the patient’s care. To help RNs better document care, here are some best practices for documenting patient care:

• Create an Accurate Patient Chart: Start by creating an up-to-date patient chart that accurately reflects the patient’s current medical condition. This includes recording the patient’s demographic information, medical history, diagnostic tests, treatments, and medications.
• Communicate Effectively with Team Members: Documenting care can be challenging if you’re not regularly communicating with the patient’s other healthcare providers. It’s important to maintain open communication with team members so that everyone has access to the same information.
• Stay Organized: It’s also important to stay organized when documenting care. Record all patient information in one place and use standardized forms and templates that are easy to follow.
• Update Care Plans Regularly: Care plans should be updated regularly to reflect any changes in the patient’s condition or treatment. Document how the patient is responding to different treatments and keep track of any modifications you make to the care plan.
• Be Timely: Make sure to document patient care in a timely manner. Prompt documentation ensures that all healthcare providers have access to up-to-date information in a timely fashion.

By adhering to these best practices for documenting patient care, RNs can ensure that their patients receive safe, quality care. For more information about documenting patient care as a Registered Nurse, please visit the following resources:

• Documentation of Patient Care from American Nurse Today
• Effective Nursing Documentation from Nurse.org
• Nurses’ Documentation Practices: A Qualitative Study from The National Center for Biotechnology Information