Documentation

There are many different fields of health care in which you may end up working such as: nursing homes, doctor offices, hospitals, out-patient surgery offices, and many more.  In healthcare documentation of everything you do for a patient is very important in order for the patient to receive the best care.  Documentation is also important since it is a record of what you have accomplished for your employer to view.  Documentation is primarily done on a computer.  Different facilities may use a different program for documentation, but they are all similar.  It is important to make sure that your documentation is clear to others.  You should also use professional terminology within your documentations.  Documentation is also used for billing purposes, if there is no record of the services the patient has received, then insurance cannot bill for it.  Documentation of a patient leaves a long paper-trail of their previous medical history, medications that they are on, treatments they are receiving, and all other details of the patients’ medical needs.   Documentation is a very important process in which a health care provider will use from day to day.

I recently transferred to a new job, working in the Emergency Department.  I am still in my first month in my new position, but have already realized how important that my documentation is.  Before my first day on the floor I had to take a class on the EPIC documentation system that Carilion uses.  It is amazing to me how much information this system has on each patient.  Since I began on the floor, I have realized how necessary that my documentation along with everyone else involved in a patients care is.  I find myself checking EPIC in between every patients room to make sure that nothing new has come up that needs to be addressed.  I believe that my experience in my current job will be very helpful to me in my future as a nurse.