when to document in patient notes

[sheila2155]

Hi everybody
my question concerns staff nurses. any nurses out there who can tell me - with three shift patterns - earlies, lates and nights, when is it not my duty to document patient care during a shift? on one ward i was told it wasn't necessary to do a record of care on lates if there are no changes to report on the patient. is this legal in a court of law. can't find any reference in the nmc website to this.

[meltoadhall]

I always like to document something even if it only says no changes, I dont know about the legalities, but it proves that I have seen the patient and noted no changes.

[chelsea78]

Hiya, i work in a care home and i no that you aint to write (no change) in legal documents coz what does that actually mean? notes need to be more percific then that, if i were you i would check it out with in charge just to cover own back, nvq's tell you this.

[meltoadhall]

registered nurses in NHS hospitals write this all the time, on the basis that if it isn't written down then it didn't happen - NMC code of conduct.

[alijangra]

On a late shift I would always feel it necessary to remark on patient appetite, fluid intake, mood etc but it really depends on what area you work in. I work in the community and always document everything I do with each patient, I notice other nurses only document when there are changes. At the end of the day it is a legal document, and writing 'no changes' at least indicates that documentation has not been overlooked. In a situation where 12 hour shifts are worked, with no staff changes, then a daily entry is sufficient. However, where a staff change has occurred they really should be documenting something. Poor documentation is dangerous and leads to many problems.