2. Do you fail to record absolutely everything you do for a patient?
You change a dressing. Do you record it, along with your observations about the wound? You follow an order to give a patient medication. Do you record that you have given the medication? If you don’t record what you do, and then your shift ends and you leave, think about the position in which you’re putting the next nurse.
Don’t put off charting. Do it as soon as possible after you carry out an action. Sure, it takes time and you’re busy, but charting the care you give is as important as providing the care.