You will use this skill every single shift without fail so we gotta get good at it hello everyone it's nesari here and welcome back to the clinical skills series in this channel i make videos about nursing life student nursing videos and more recently my clinical skills series now what is the clinical skills series these are a series of videos focusing on nursing clinical skills that you will commonly find out in practice or in placements the most important aspect to these videos is the patient scenario section they are designed so you can follow along and hopefully by the end of this video gain confidence in the skill today's clinical skill is nursing documentation a highly requested video you will use this skill every single shift without fail so we gotta get good at it now without further ado let's begin what is nursing documentation nursing documentation is a formal record detailing the nursing care provider to an individual by a qualified nurse it is our duty as nurses to keep our notes up to date not only for the safety of our patient but also to stay on the right side of the nursing and midwifery code of conduct your nursing notes are evidence of the care you have provided and can stand as a legal document in the event of a complaint or incident that takes place we have this famous nursing proverb which is if it wasn't documented it didn't happen so i hope i have emphasized the importance of documentation so far now naturally working in the wards and documenting nursing notes is going to be different to if you were working as a general practice nurse out in primary care so remember always ensure that you are documenting correctly with your clinical...
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About Daily Skilled Nursing Notes
Daily skilled nursing notes, also referred to as clinical narrative or progress notes, are a record of a patients health status, including any changes or progress observed by the nurse or healthcare provider. These notes contain essential information such as vital signs, medications taken, procedures performed, symptoms observed, and responses to treatments. Daily skilled nursing notes are needed by healthcare providers who are responsible for the care of a patient who requires ongoing skilled nursing care. This includes patients who are recovering from surgery or illness, those with chronic or serious medical conditions, and those in long-term care facilities. The notes are used to track the patients progress, identify potential issues or complications, and provide a comprehensive picture of the patients health over time. The notes are also used by other members of the healthcare team to communicate with each other and ensure continuity of care.
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