Document or die

WRITE EVERYTHING DOWN.

“Cannula sited in antecubital fossa, 1L normal saline given over 4hours”

“Patient swore at me and told me not to examine him”

“Patient seen in corridor”

Simple as that. It’s good practice, it makes it easier for those taking care of the patient later on, and it provides invaluable protection in any legal situations. It also shows you know what you’re doing and makes the hospital run more smoothly.

 

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