Do's and Don'ts of Nursing Documentation

Nurses are well aware of the standards, which states that if a certain matter affecting patient care is required to be charted and it is not, the overwhelming presumption is that it may not have been done. Good documentation will help you defend yourself in a malpractice lawsuit, it can also keep you out of court in the first place. The following excerpts are courtesy of NSO Risk Advisor-January, 1977.

Do's

* Check that you have the correct chart before you begin writing.
* Make sure your documentation reflects the nursing process and your professional capabilities.
* Write legibly.
* Chart the time you gave a medication, the administration route, and the patient's response.
* Chart precautions or preventive measures used, such as bed rails.
* Record each phone call to physician, including the exact time, message, and response.
* Chart patient care at the time you provide it.
* If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry.
* Document often enough to tell the whole story.


Don'ts

* Don't chart a symptom, such as "c/o pain," without charting what you did about it.
* Don't alter a patient's record - this is a criminal offense.
* Don't use shorthand or abbreviations that aren't widely accepted.
* Don't write imprecise descriptions, such as "bed soaked" or "a large amount."
* Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately.
* Don't chart care ahead of time - something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.


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