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.

For More Information

• Surefire Documentation: How, What, and When Nurses Need to Document Explains how, what, and when to document for nearly 100 on-the-job situations. Provides specific information on: caring for patients, dealing with challenging situations, and handling difficult professional problems. Includes pertinent information highlighted in boxes
• Nursing Documentation : Legal Focus Across Practice Settings It is the only book of its kind to combine legal issues with charting methods and an extensive review of practice settings where documentation varies greatly...
• Charting by Exception Applications: Making It Work in Clinical Settings Practical manual for nursing administrators or supervisors on implementing charting by exception (CBE), an time-efficient and cost-effective method for documenting care delivery.
• Avoiding Malpractice: 10 Rules, 5 Systems, 20 Cases A lawsuit for malpractice is emotionally devastating for a nurse practitioner, and obviously arises out of a tragedy for a patient. I believe there is a place for preventive law, just like there is a place for preventive medicine. I would rather work on preventing malpractice than litigating it...
• The Health Care Provider's Guide to Facing the Malpractice Deposition Designed to equip those in the health care industry with the tools necessary to come out of a malpractice deposition with as few 'bruises' as possible. Topics include law and legal thinking, standard of care, preparing for the deposition, and common forms of interrogation.
• Nursing Malpractice : Liability and Risk Management Students and professional nurses at any level of clinical practice will find this book to be a vital resource on the basic legal concepts and principles of malpractice, liability, and risk management, and their implications for the profession. The book also provides detailed strategies for dealing with these issues.
• Proper Charting For Nurses And Other Health Care Professionals The following are some tips to keep in mind when charting. These are not all inclusive but they do provide a general guideline for the nurse and other health care professionals. [Male Nurse Magazine Article]