Specific guidelines apply regardless of the documentation format you use. The following tips will help ensure that your recordkeeping can be defended in the courtroom.
Legibility is essential. Never second-guess someone else's writing. Call the colleague for clarification, if necessary. Correct spelling and proper grammar are crucial for safe patient care because they enhance your professionalism. Ensure a dictionary is kept at the nurses' station and post a list of commonly misspelled words. Avoid abbreviations altogether when possible. If you must use them, use only abbreviations approved by your facility.
Make sure you have the CORRECT CHART for the CORRECT PATIENT before you begin writing. The medical record is a permanent legal "business record," and entries must not be made in pencil or erasable ink; write in permanent ink. Stick to blue and black ink. As a rule, courtroom proceedings will use copies of the record. Copying and electronic scanning machines duplicate blue and black ink with the highest clarity. If you use a highlighter in your record to note discontinued medication, ensure that your medical records department can effectively copy highlighted information — some copy machines "gray out" any writing covered by the highlighter.
If anything is secured into the medical record with tape (monitor strips, blood product labels, etc.), use double-sided tape or tape only onto blank paper. Even though the tape is clear and can be read through by the naked eye, a copy machine may "black out" the taped area. Faxes must be copied before inclusion in the chart. Unless you have a plain paper copy machine, the ink on the fax may be water-soluble and fade in a few days.
EVERY PAGE of the record must have the date and patient name; this is required for a record to be admitted in a courtroom. Your complete signature is required once per page. Your full signature is your name, followed by your professional designation. When adding a progress note, follow institutional policy to determine if you are to note the time that the entry is being added rather than the time that the observation took place.
Avoid block charting, such as "11:00 PM to 7:00 AM," as it gives the impression of vagueness. Note the exact times of all critical treatments, physician contact, or notices to supervisors. Any time you leave a message with someone in a physician's office, note the time and the name or title of the person taking the message.
Make sure the "proper" person does the documentation. For example, The Joint Commission (TJC) states that an RN should perform and document the initial assessment and care plan (TJC, 2016). Documentation by the proper person is essential in educational, nutritional, and rehabilitation assessments.
Avoid documentation practices that either allow or allude to the alteration or falsification of a medical record. Eliminate excess white space in your record. When making a progress note, write flush to the margin. Likewise, when you have completed your thought, draw a line through any remaining blank space on the line before signing your name. Do not leave blank lines between entries.
Do not make entries in advance. Wait until things happen before marking them down. Even the most predictable events can get off schedule in patient care.
To correct written entries, put a single line through the error, then add your initials and the correction date. You may note "error" or "mistaken entry." Do not use whiteout or tape designed to obliterate typographical errors. Do not correct another's error. Likewise, if you disagree with an entry, do not record your opinion next to the disputed entry. Discuss your conclusions with a supervisor to ensure that the patient receives the best care and that the chart reflects respect for all healthcare team members (American Health Information Management Association [AHIMA], 2014).
When possible, chart as soon as possible after you make an observation or provide care; this helps eliminate the chance of forgetting important data. Late entries, out-of-sequence entries, or addendum entries may sometimes be necessary. If the entry is made the following day, always cross-reference the entry so that the reader will read the additional note in the proper sequence. The following steps will eliminate misunderstanding:
- Add the entry to the first available line.
- Indicate clearly "late entry."
- Record the day and time you are writing the entry.
- In the body of the paragraph, indicate the day and time of the previous event now being described.
Never chart for someone else. Do not write anything if you did not participate in an activity or observe someone else's care. If you are on duty when a nurse calls to report that she forgot to record a patient interaction, chart it in the following way:
"At 8:35 AM, Nurse Joann Green called and reported that at 5:30 AM this morning, she observed…."
Understand countersigning. Only countersign notes when required by the institution.
- If you merely review someone's note, co-sign in the following manner:
- "Student nurse name/Entry reviewed by Jane Doe R.N."
- If you actually participate in the activity, co-sign in the following manner:
- "Student nurse name/Jane Doe R.N."
Keep documentation objective. Do not chart opinions or assumptions. Rather than "the patient was unresponsive," your notes should report what you saw through objective assessment. Document what you see, hear, or smell. Avoid phrases like "perhaps,” "maybe," or "I think."
Be careful to avoid labeling the patient. For example, avoid descriptive terms like "demanding,” "drug seeking,” "abusive,” "lazy,” "drunk,” "mean,” "litigious," or "out-of-control." Instead, note observations as a description of the behaviors.
Unusual occurrences and patient injuries need to be documented. Objectively record what you witness without making any conclusions or unsubstantiated assumptions. Use quotation marks when documenting comments from the patient, roommate, or visitors. Record the patient's vital signs, physical condition, mental condition, subjective complaints, physician's notification, arrival, and treatment details. However, do not mention in the patient's record that an incident report or occurrence report was filled out.
Always document a patient's uncooperative behavior. For example:
- leaving against medical advice
- refusing or abusing medications
- failing to follow a diet or exercise plan
- refusing to follow instructions to stay in bed or ask for assistance
- failing to give information that affects care, such as complete history, current medication, or treatments
- patient or family tampering with traction, IVs, or monitors
- failing to follow up with visits to a clinic or physician
- bringing unauthorized items into the facility
Document any safeguards or other preventive measures to protect your patient (e.g., night light left on, call light available, floor clear of trip hazards, etc.).
A chart should note that the facility's safekeeping for valuable possessions system was explained and made available to the patient. Encourage the patient or family members to send any possessions home. If they agree, have them sign their names next to a documented statement. Discuss the availability of a safe and ensure that all items put in the safe are recorded on a receipt complete with the patient's name and ID number. Describe each item in detail using objective language, for example, a “yellow ring with a clear stone” instead of charting a “gold diamond ring.” Update the list of valuables frequently for long-term patients. Before a patient is transferred, take an inventory of the list of valuables to verify the location of the items.
Document medication administration as thoroughly as possible. Note the date, time, initials, method of administration, and, if applicable, the site where the medication was given. Document the site of the infusion, the type and amount of fluid, any medications added, and the administration rate of IV infusions. At least once a shift, note the condition of the IV site and the type and size of the catheter (FAC, 2013).
If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the drug. When omitting a medication, document the rationale. For example, "pain medication held pending stabilization of vital signs." If a medication order is being questioned, tactfully document your conversation with the physician. If someone is giving your patient medication while you are off the unit, ensure that person charts that they administered the drug.
Avoid verbal and telephone orders whenever possible because of the high risk of errors. However, since it is not always possible, the proper method for documentation of verbal or telephone orders includes the following:
- Time and date of the phone call
- Write the order verbatim, and then read the order back to the physician
- Document T.O./R.B. (telephone order/read back) or V.O./R.B. (verbal order/read back) followed by the physician's name and your name
It is easy to fall into the trap of quick charting as tasks and responsibilities build up. However, care should be taken to avoid common charting errors (FAC, 2013). These common errors include:
- failing to record pertinent health or drug information
- failing to record nursing actions
- failing to record that medications have been given
- recording in the wrong patient's medical record
- failing to document a discontinued medication
- failing to record drug reactions or changes in the patient's condition
- transcribing orders improperly or transcribing improper orders
- writing illegible or incomplete records
Common documentation errors often involve specific words considered risky and should be avoided. They include:
- Could be
- May be
Charting should be FACTUAL, ACCURATE, COMPLETE, and TIMELY.
- Only information collected through your senses should be documented.
- Describe the behavior, do not label the patient.
- State facts, not value judgments such as "no change” or “ate well."
- Use neutral language.
- Avoid documenting your own bias.
- When you make an error, state precisely what you did or failed to do and that you notified the patient's provider and the provider's response (ANA, 2010).
- Be precise and quantify whenever possible.
- Be sure to make clear who gave the care.
- Review the contents carefully, especially if countersigning with someone. Be sure to perform medication calculations if countersigning (ANA, 2010).
- Document condition changes (even if there is none).
- Document patient responses, even if unusual, undesired, or ineffective.
- Document the communication/education that occurs with the patient and family.
- Ensure there are entries in all spaces on all relevant assessment forms.
- Use N/A or other designation per policy for items that do not apply to your patient.
- Do not leave blanks. Blanks are hazardous as they allow for additional entries not made by you. Others may make entries in such blanks by mistake or to purposely falsify records. Be sure there are no blanks at the bottom of the previous page (ANA, 2010).
- Date and time are critical in establishing a timely response, and they are necessary to be legally upheld in court. Electronic entries are automatically stamped with the date and time. If you refer to an earlier entry, be sure to note that.
- Do not chart in advance, and do not leave documentation until the end of the shift. Advanced charting is considered record falsification and is illegal. It also contributes to confusion and may ultimately harm patients. It is easy to forget critical pieces when rushing to document.
- It is easy to forget to document when managing several patients; ensure there is time to document between care when possible. Charting as the shift progresses will help keep your documentation more manageable and in a sequential manner.
- Without thorough documentation, you must rely on your memory of events; this may not hold up in a court of law.
- Colleagues providing temporary coverage or who take over care will rely on up-to-date information documented in the chart (ANA, 2010).