Do's and Don'ts of Documentation

Good documentation can help nurses defend themselves in a malpractice lawsuit, and keep them out of court in the first place. 

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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: 


  • 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’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. 

Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)

What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 

The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 

How does a shared limit policy work?

A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.

We have a shared limit policy. Are employees covered if they practice outside our office?

The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.

There are plenty more where those came from.

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