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: 
 

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.