Documentation
Documentation is the process of preparing a complete record of a patient’s care and is a vital tool for communication among health care team members. Accurate, detailed charting shows the extent and quality of the care that nurses provide, the outcomes of that care, and treatment and education that the patient still needs. Thorough, accurate documentation decreases the potential for miscommunication and errors.
Documentation is a valuable method for demonstrating that the nurse has applied nursing knowledge, skills, and judgment according to professional nursing standards. In a court of law, the patient’s health record serves as the legal record of the care provided to that patient. Accrediting agencies and risk managers use the medical record to evaluate the quality of care a patient receives. Insurance companies use documentation systems to verify the care received. Nursing documentation in the medical record may also be used for research and education as well as for quality improvement programs.
Equipment
Medical record (electronic or written) ▪ pen with black or blue ink, if using a written medical record.
Preparation of Equipment
There are various systems used for documentation. Because each documentation system follows specific policies and procedures for charting, you should familiarize yourself with the requirements of each system. (See Comparing charting systems.)
Implementation
Write legibly because illegible entries can result in misinterpretation of information and possible patient harm.
Use ink because the medical record is a permanent document and ink can’t be erased.
Sign all entries using your first and last name and title to clearly identify who wrote the entry.
When signing your initials on a form, use your full signature in the appropriate place on the form to identify yourself as the care provider.
Ensure that each sheet of the medical record contains the patient’s identifying information to avoid documenting on the wrong patient or mistaking the patient for another.
Use correct spelling and grammar in your entries because misspelled words and poor grammar look unprofessional and can lead to errors.
If you make an error, draw a single line through the mistake and make a notation, such as “documentation error,” and initial it along with the date and time according to facility policy. Then, record the correct entry. Don’t use correction fluid, erasures, or entries between lines.
Don’t leave blank lines within and between entries. Draw a line through the blank line to ensure that no further entries may be made.
Document in chronological order using the correct time and date. Avoid block documentation, which is vague, implies inattention to the patient, and makes it hard to determine when specific events occurred.1
Document time according to your facility policy using 24-hour military time or including a.m. or p.m.
Document information as soon as possible to ensure the accuracy of the information and to reflect ongoing care. Delayed documentation increases the potential for omissions, error, and inaccuracy due to memory lapse.2
Describe observations and behavior of the patient rather than “label” the patient. Don’t offer opinions or use subjective statements or judgments.
Use only approved abbreviations.3 (See Abbreviations to avoid, page 232.)
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