Description
There are occasion that patient documentation were not accurate as demanded by a professional nurse and it has been highlight is part of learning needs to improve upon. I have also noticed some errors in writing in terms of the grammatical errors.
Feelings
I unease if the information obtained is not document the way that is received and that make me feel the care given has meet its objective. At the end of a shift I need to assess my self whether the goal setting is achievable and the only is look at my documentation and contemporary notes. I felt poor proper documentation may be difficult for teamwork to progress hence meeting holistic care of the patient
Evaluation of experience
I would say English …show more content…
Communicates with staff, patients, family members and other professional and document as appropriate as possible.
Spinner
Reflection on documentation
Description
There are occasion that patient documentation were not accurate as demanded by a professional nurse and it has been highlight as part of learning needs to improve upon. I have also noticed some errors in writing in conditions of grammatical errors.
Feelings
I am unease if the information obtained is not document the way that is received and that make me feel the care given has not meet its objective. At the end of a shift I need to evaluate myself whether the goal setting is achievable and the only way is to look at my documentation or care notes. I felt poor documentation may be difficult for teamwork to progress hence meeting holistic care of the patient
Evaluation of experience
I would say English is not my first language and as such is difficult to construct some sentences and words which are meaningful. I have been managing to write as accurate as possible as it can be
I would say sometimes when I am under pressure of work load it influence my writing and documentation at …show more content…
On the other some of the information's documented needs to be clear, concise and eligible for others to read it for continuity of care. It is asserted that two way of communication should be able to receive and give a feedback and that shows that communication has fulfil its purpose. In conditions of nursing documentation is quite crucial because of court of law and the ethical reason in providing care of the patient makes the nurse accountable and liable for their own action. incidents with patients and staff, one need to ensure whatever I incident information about patient must be document as accurate and precise. More also telephone and email information causes a lot of problems and one must be careful of what information that is pass on to other department because once delivered is hardly to retrieve or delete it because the internet data base system is very complex to