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If it isn't written down, it wasn't done.(Editorial)(Editorial)
- Article from:
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Oncology Nursing Forum
- Article date:
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May 1, 2008
- Author:
- Carroll-Johnson, Rose Mary
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Copyright informationCOPYRIGHT 2008 Oncology Nursing Society. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be directed to the Gale Group. (Hide copyright information)
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A sophomore nursing student in her first medical-surgical rotation charted the following: "Pt. ambulated to the bathroom with assistance." However, the student abbreviated assistance as "ass." The student's instructor grasped the teachable moment by commenting aloud that it would have been pretty difficult for the patient to go anywhere without that body part! Thus was I introduced to the nuances of correctly documenting my nursing care.
Through the years, nursing has struggled to find a documentation system that would be accurate, quick, comprehensive, meaningful, and read. Remember SOAP charting? Charting by exception? Remember the battles over who could write on nursing ...