Great note taking has been a vital tool of communication between doctors, nurses and patients. This ensures the health care record of the patient as it is an accurate account of planning, treatment and delivery. Contemporaneous notes are essential to ensure that patient is receiving the highest level of care, no matter what nursing field you have specialized in.
If there are no proper nursing notes it would become difficult to find evidence of medical decisions, planned care and treatment delivered to the patients.
Tips to improve note taking skills:
As the nursing field has the potential legal nature, it is crucial to take the highest quality nursing notes on all patients. This is certainly a big challenge due to the number of patients seen on daily basis. Therefore taking contemporaneous notes should be a strong habit. Here are some tips to improve the skills of taking nursing notes:
A. Be objective:
It is important to make the notes factual, accurate and unambiguous when it is matter of a patient. Always make clear statements that carry the fats. No dual meaning and no confusing terminologies are to be used.

B. Use your senses:
The level of detail that you will be able to recall is one of the major benefits of taking notes. The notes you have made on a patient can be shown and discussed with colleagues and officers as well. In this way you will become more engaged and focused in patient’s care and the legal staff will get a clearer picture of quality of care the patient is receiving. Try to anchor your notes with the details that show the involvement of your senses like ‘I heard’, ‘I saw’ or ‘I felt’ etc.

C. Quoting patients:
As quoting notes is a powerful detail, it should be added to the contemporaneous notes whenever possible. Punctuation marks stand out and let the readers provides essential information at once as well as provides clear evidence of communication between you and the patient. This could also be an active part of police notes.

D. Providing evidence :
The medical records are used to be updated with fresh information; therefore viewing the notes as potential legal document is very important. It can be helpful in justifying the actions in the course of taking your contemporaneous notes.

E. Document objections:
Sometimes during the course of your nursing career you have to encounter the medical decisions made by the staff but you do not agree with. Though it is not common yet possible that you need to protect yourself in such a situation. Therefore you should be objective as much as you can and provide the required evidence. Similarly, the work-place harassment notes and the police notes are very important to maintain.



Find more information relating to Contemporaneous Notes, and Work-place harassment here.
ContemporaneousNotes.com
contemporaneousnotes.com
NY, New York, USA
[email protected]