Documenting what you do

My wife has pulmonary fibrosis, so we spend a lot of time in doctor's offices and hospitals. It's always a joy for me to observe and compare how one nurse handles certain situations than another. Personality shines through everything you do.

One thing that we've struggled with is the lack of documentation of how certain things work. Specifically, the notes left in the chart from each visit that other nurses and doctors consult at the following appointments.

We were in the hospital for a few days in a row one time and my wife was getting an antibiotic through an IV. One morning, she was getting the IV and it started to burn. So, the attending nurse turned the flow rate down a little bit. That seemed to solve the problem. Yet, that nurse didn't document in the chart this rate change.

Later that same night, when the nurses started the antibiotic once more, it started to burn again. We told them the nurse earlier in the day slowed the flow rate and that helped. But, lo and behold, they checked the chart and didn't see any documentation of the rate change. So, they had no idea what number to go down to or why that may have solved the problem. Instead, they stopped the flow of the antibiotic. This meant we had to wait for the head nurse to come in and guide us on the next steps.

I suspect this happens in every company and on every team. But it's a great illustration that explains the importance of documenting what you do.


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