Rachel's Blog

The entries you make in the medical record should show you took appropriate actions in response to the patient’s condition. Record as close to the timing of the events as possible otherwise you may not remember key points, times, or persons that are important to record.  Record “real-time” when documenting interventions.  Real-time entries may avoid …
It is not always easy to make documentation a priority.  Time constraints may lead you to think that other patient care activities are more important, particularly in a crisis situation.  Often documentation is pushed to the bottom of the list of priorities.  To help prevent documentation from becoming a burden, organize patient care information into …
Abnormal vital signs. A significant deviation from what is considered to the patient’s normal requires an entry detailing what is being done about it. For example, deviations may be fever, elevated BP, or slow respiratory rate. If your response is to monitor the patient more closely, then write that in the medical record followed by …