How do you approach the documentation of patient records? Do you have specific strategies that you use?
Documentation of clinical encounters in patient records is extremely important as a NICU nurse. If clinical encounters, medications, procedures, vital signs, and other information are not documented properly, poor, or even fatal, patient outcomes could occur. Your interviewer is asking this question to determine how seriously you take accurate and timely documentation and to see if you use any methods to improve efficiencies for documentation.
"I approach patient documentation in the EHR very seriously. As an RN, my work needs to be documented so my colleagues remain updated at shift time and providers are updated on the care provided for patients. Even on the busiest of days in my current unit, I make the time to finish charting right away in the patient's room. I fully realize that there are extra precautions that need to take place in the NICU regarding patient documentation and that the misidentification of patients is a very real risk."
To effectively answer this question, be prepared to talk about how you approach documentation from beginning to end and give examples of any strategies that you use to improve efficiency. If possible prior to your interview, do some research on common errors that occur in NICU patient documentation so you can assure your interviewer that you are aware of the importance of accurate documentation and assure them that you will take the necessary time, every time, to document patient notes.
"I try to document in real time as much as possible, while things are fresh in my mind and I'm focused on that patient. I always ensure my charting is done before the end of my shift, and I never leave that for another person to do. I am very detail-oriented, so I'm diligent in making sure that everything in my charting is accurate. I also make sure I lock my computer station when I'm away from it, to prevent unauthorized parties from accessing charts."
