NURS 360 Health & Illness III

Reflective Journal
Week #2. Evaluate legal principles, nursing standards and ethical concepts in the
management of nursing care of clients.

Was I able to document in an organized complete and accurate manner? (Describe

any problems encountered).

As I prepared for the second clinical week, I stayed mindful of improvements I wanted to
make from last week. One in which was to ensure organized and accurate documentation. I
went ahead and created a personal time table and check list for myself to refer to during both
clinical days. The purpose of a time table is to ensure that all scheduled treatments and nursing
orders are completed and done so in a timely manner. It also entails necessary skills that are
routinely done such as checking vital signs, safety checks, checking lines/drains/tubes that the
patient has, head to toe assessments, other assessment tools utilized, skin/wounds, and progress
note (DAR note) that needs to be documented by the end of my shift.
I believe that I was able to document all of the components in part of my patients care
this week. I also learned that there is a flowsheet for every noted or procedural wound. In the
patient summary, I had recalled seeing a nursing order for the dressing change of the patients GT
site daily. However, on the second day of clinical as I was working on my DAR note, I no longer
saw it written there. I felt myself become flustered because this made me realize that I need to
continue to check my nursing orders for any discontinued or new orders that may have been sent.
Professor Ottoson articulated that I can document about my care and assessment of the GT site in
a specific flowsheet. The primary nurse also assisted and guided us on placing this flowsheet.
Now I am gradually expanding my assessment and documentation skills with the electronic
medical chart. It is important to maintain efficiency and consistency in inputting documentation
on time. I can develop this healthy habit by completing my initial assessment then immediately

documenting the assessment after. This technique will prevent me from putting off
documentation of these important assessments when irrelevant and also from preventing a backup of everything that needs to be documented from my shift and its associated stress. Early
documentation also ensures that nothing was overseen or missed, that my documentation is
correct, and that I have completed my documentation in a timely manner that correlates with
scheduled or as needed nursing care. Also, ultimately, as I pick up more patients and become
more equipped to take on a full load, I will have acquired productive and effective
documentation skills that will enable me to implement this priority nursing skill in an accurate
and organized manner throughout a very busy shift.