Avoid Haunting Documentation

The words you choose in charting today could come back to haunt you tomorrow. Some-times, seemingly harmless bits of information you write in a patient's medical record can hurt you in a lawsuit. For example, certain terms--such as "by mistake," "accidentally," "miscalculated," or "confusing" conjure up images of nursing errors and compromised patient safety. To prevent problems when writing your nurse's notes, don't use words that express an opinion. Instead, document only the facts. Here's a good example of factual documentation, made after a physician ordered 50 mg of Demerol:

Patient was given Demerol 100 mg I.M. at 1400 hours for abdominal pain. Dr. Shaw notified but gave no orders. Pt.'s vital signs remained stable.

This entry is a factual account that lets others know the physician's order for 50 mg of Demerol wasn't followed. *