tag:blogger.com,1999:blog-4297301321247868053.post4935852500642800804..comments2023-05-30T23:27:57.848+08:00Comments on Infomidwife: Poor Record Keeping has Midwife CautionedInfoMidwifehttp://www.blogger.com/profile/00843289052323073178noreply@blogger.comBlogger2125tag:blogger.com,1999:blog-4297301321247868053.post-79679542813886131422008-09-11T09:23:00.000+08:002008-09-11T09:23:00.000+08:00Thanks Suzanne, you make some valid points. I thin...Thanks Suzanne, you make some valid points. I think as health professionals we need to constantly remind our colleagues about good documentation. It is a sign of our professionalism and needs to be promoted and encouraged by management as a priority. When caring for our patients/clients anything abnormal needs to be reported, documented, plan of action, then followed up and again document the resuts.<BR/>It is when things go wrong (patients complaining about their care or litagation) our notes are scrutinised and if it is not written it is not done!InfoMidwifehttps://www.blogger.com/profile/00843289052323073178noreply@blogger.comtag:blogger.com,1999:blog-4297301321247868053.post-61226505961173855832008-09-10T11:47:00.000+08:002008-09-10T11:47:00.000+08:00I do agree with "not written = not done". I always...I do agree with "not written = not done". I always have problems with the newly graduated nurses or sometimes fellow batch mates and senior nurses. They seldom document the relevant and significant events. When I need to look back the report for certain events, I just cannot get any information out of their reports. Even highly trained staff in ICU are also guilty of poor documentation.<BR/><BR/>I still can remember one incident where my Junior (also a RN) and me have to scrutinise all the doctors notes and nursing reports just to find out when was the chest tube removed. We gave up eventually and called the ICU. None of the nurses who nursed him could provide us with the information. In the end, we have to speak to the nurse clinician directly. It is such embarrassment that as you go on nurses, your skills and knowledge improves yet such things still happens. The fault also lies with the receiving nurse, who is very senior, overlooked that information.<BR/><BR/>What is a good documentation? Writing accurate and significant events with the date and time and signed off by the RN IC. I've met incidents when patients complains and I was never usually called up as my reports were sufficient enough to cover myself and my junior, sometimes even my manager if she is involved. The only time I was called up was when I was working as Junior and my IC did not write a proper report. I had to write a memo and also to see my nurse manager just to explain what I did that day. Nothing serious happened, its just that documentation can save up a lot of time and trouble.<BR/><BR/>From what I understand about the education system here and my country, the preaching for documentation is the same. Sometimes its during the time of forgetfulness, or slackness, or the overwhelming of events that lead to poor documentation. Whichever the case, for patient's life, there is never 'cut some slack' for us all in the health care. When did we actually cut a slack for ourselves? When we are fully taking a break and not working?<BR/><BR/>Nonetheless writing a report is never difficult, practice makes perfect. Save the patient. Save yourself and save those looking after the patients too.Suzannehttps://www.blogger.com/profile/00629469150821860085noreply@blogger.com