Anyone who knows me knows that I eat, sleep and breathe triage, but especially documentation. That, after all, is a huge part of a triage nurse's life. Or, at least it should be.
Every time I think of documentation, I remember a nursing school school instructor's words ringing in my ears, "If it isn't written, it wasn't done". And so many times, when you examine a note, it appears it wasn't done, because the nurse forgot to add it. This is so easily done in our fast paced environment, but that one little sentence you forgot to add could be your down fall in court.
I like to compare notes to reading a mystery novel. You should be able to pick it up, not knowing anything about the patient, and it give you a story from beginning to end. If it does not, something is missing.
The story should begin with the concern that the caller is reporting, and related symptoms. Details are the adjectives, who, what, when, where, and to what extent. Descriptions should be as complete as possible and paint a picture of the problem.
The body should include treatment that has been tried for the problem, if any, and the outcome.
The ending should include your advice to the caller, including protocols referenced that were followed. If any advice is given that is not included in the protocol, then it must be spelled out in the notes. If it is not, you cannot prove it was done. This is where so many nurses make their mistakes, and the story leaves you hanging. You do not know the ending, and no one likes being left at the end of a mystery with no conclusion.
So, strive to give all your stories an ending, and leave the reader satisfied that they got the complete story.