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Nursingdegrees > Nursing Resources  > Dos and Donts of Nursing Documentation

Dos and Donts of Nursing Documentation

Proper nursing documentation will, most importantly, ensure that your patients receive the highest quality and correct care in response to their symptoms. Legally speaking, proper nursing documentation will help you defend yourself in a malpractice lawsuit, and 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 a 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 also 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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