Registered Nurse Mock Interview
Master 30 Registered Nurse interview questions covering clinical scenarios, patient care priorities, and critical thinking.
Question 28 of 30
How do you approach the documentation of patient records? Do you use specific strategies?
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Ryan Brunner has over ten years of experience recruiting, interviewing, and hiring candidates in the healthcare, public service, and private manufacturing/distribution industries.
Documentation of clinical encounters in patient records is essential at this organization, and much of this responsibility rests on the shoulders of the Registered Nurses. If clinical encounters, medications, procedures, vital signs, and other information are not documented correctly, unintended consequences could occur, some being dire. 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. To effectively answer this question, be prepared to talk about how you approach documentation from beginning to end and give examples of any strategies you use to improve efficiency.
Ryan Brunner has over ten years of experience recruiting, interviewing, and hiring candidates in the healthcare, public service, and private manufacturing/distribution industries.
"I am new to nursing, as I just finished nursing school, but I understand how important clinical documentation is. During my clinical rotations, when I had the opportunity to document my clinical encounters, I made sure to document everything. Before signing the note, I would double-check to ensure everything was correct. Since I am new to this and have not had a chance to develop my efficiencies, I cannot speak to that. Still, I can say that my background in IT project management will allow me to think outside the box, and I can see myself coming up with ideas for standardization. If hired at your organization, learning and mastering the EMR would be one of my first goals during orientation."
Working on a unit can be hectic, so I need a system for my charting. Ideally, I chart after each encounter with a patient. Sometimes this is not possible, depending on the needs of my other patients. So to help me, I keep a cheat sheet of my assessment of a patient, vital signs, and any scheduled or as-needed medications. Then, as I give medication, I update my paper so I know when to check back with the patient. After leaving a patient's room, my goal is to chart that encounter with the patient right away so I don't get behind. If I chart after each patient, things will stay up to date in the chart, and my shift will go much smoother. If I need to go into another room quickly and do not have an opportunity to chart right away, I have a system for helping me to remember. Because I have written down on my cheat sheet what I did, once I chart it, I put a line through it. That guarantees that I will get it charted and will not miss something.
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