Discussion Prompts

• Identify three tips you would like to share with your peers regarding the content in the resource.
• Describe how you plan on implementing these tips throughout nursing school and into your nursing career.
• Be sure to cite your resource using APA (7th ed.).

Citation: Nurses Service Organization. (n.d.). Do's and don'ts of nursing documentation. https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation

Do's and Don'ts of Documentation.

Good documentation canhelpnursesdefendthemselvesin a malpracticelawsuit, andkeep them out of court in the first place.

Download the infographic pdf Make sure all documentation is complete, correct, and timely. Sloppy documentation practices can be used against a nurse in a malpractice lawsuit. Here are some good tips to follow when charting:

Do's

• Before entering anything, ensure the correct chart is being used
• Ensure all documentation reflects the nursing process and the full extent of a nurse's professional capabilities
• Always use complete descriptions
• Chart the time medication was administered, the administration route, and the patient response
• Chart precautions or preventative measures used, such as bed rails
• Record any phone call to a physician, including the exact time, message, and response
• If a patient refuses to allow a treatment or take medication, document it and be sure to report to a manager and the patient's physician
• Always chart patient care at the time you provide it; it is too easy to forget details later on
• If something needs to be added to documentation, always chart that information with a notation that it is a late entry and include the time and date
• Always document often enough and with enough detail to tell the entire story

Don'ts

• Don't chart a symptom such as "c/o pain," without also charting how it was treated
• Never alter a patient's record - that 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 excuses, such as "Medication not administered because it wasn't available"
• Never chart what someone else said, heard, felt, or experienced unless the information is critical. If absolutely needed, use quotations and properly attribute the remarks
• Never chart care ahead of time, as situations often change and charting care that has not been performed is considered fraud

While charting may seem like a menial and repetitive task, demanding the highest quality of documentation for every patient protects all nurses from accusations of malpractice and ensures the best care for all patients.