August 24, 2019
As a part of alumni engagement -2019, Manipal School of Nursing, MCON, MAHE, Manipal has organized a session by Ms. Vimal D’mello ( alumnus DNM 1989 – 92), Registered nurse, North Shore Hospital, Auckland, New Zealand on the topic “Documentation in Health Care” on August 23, 2019 at Manipal School of Nursing, Manipal.
It was a lively lecture cum discussion by Ms. Vimal D’mello. She stressed on the point that documentation is essential in patient care, primarily to safeguard us when we confront with any issues. She took us through different types of documentation like SBARR, SOAP/SOPIER, flow chart, checklist, narrative charting, etc. She said, "Nursing documentation must be factual, objective, clear, instant, dated, and signed. It should be done, in a way, it cannot be erased.
She added, "We nurses do a lot of things in patient care but forget to document. Even if it is a simple work, we need to document. Don't leave any space in between documentation, if there is space, draw a line, and countersign. Short forms should be avoided in the documentation. Document in such a way so that no one gets offended. If there is a mistake in the documentation, strike it off and countersign. Ms. Vimal finally sensitized us always to use phrases like please, thank you and to have a smile in between work hours. Other qualities she stressed are listening, teamwork, and helping each other.