Don’t forget to document a change in a patient’s care.
Let’s say that half-way through a shift a long-term patient has to suddenly change medications. The change obviously needs to be documented right away, especially if it is due to a sudden adverse reaction to the previous medications. If it isn't written down, the patient runs the risk of being given that same medication during the next shift.
Any changes in the patient's care, whether it is diet, medication or other, needs to be written in the files without waiting. This is also a perfect opportunity to cross-check any information with the patient's doctor and other nurses.
The same goes for any changes in the patient’s condition. Any change in the patient's health must be recorded, no matter how small that change is. It’s much easier to treat patients when their caregivers know exactly what is going on with them. This means that no matter what illness they are suffering from, or what adverse reaction they have, it needs to be recorded so it can be treated in a more timely matter.