Certain guidelines apply regardless of the documentation format you use. The following tips will help ensure that your record keeping 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, not only for safe patient care but also because they enhance your professionalism. Make sure a dictionary is kept at the nurses’ station and post a list of commonly misspelled words. Avoid abbreviations completely when possible. If you must use them, use only abbreviations approved by your facility.
Make sure you have the CORRECT CHART, for the CORRECT CLIENT before you begin writing.
The medical record is a permanent legal "business record," and as such, 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, perhaps as a way of noting discontinued medication, make certain that your medical records department can effectively copy highlighted information — some copy machines "gray out" any writing covered by 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 itself is clear and can be read through by the naked eye, a copy machine may "black out" the taped area. Faxes must be copied prior to inclusion in the chart. Unless you have a plain paper copy machine fax, the ink on the fax may be water-soluble and fade in a matter of 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 setting.
Your complete signature is required once per page. Your complete 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 p.m. to 7:00 a.m.” This type of documentation gives the impression of vagueness. Note 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 certain the “proper” person does the documentation. For example, The Joint Commission requires that the initial assessment and care plan be performed and documented by a registered nurse. Documentation by the proper person is especially important in educational, nutritional, and rehabilitation assessments.
Avoid documentation practices that either allow or allude to 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 date of correction. You may note “error” or “mistaken entry.” Do not use white out or tape designed to obliterate typographical errors. Do not correct another’s error. Likewise, if you do not agree 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 possible care, and the chart reflects respect for all health care team members.
When possible, chart as soon as you can 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 on a 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, and
- In the body of the paragraph, indicate the day and time of the previous event now being described.
Never chart for someone else. If you did not participate in an activity or observe someone else’s care, do not write anything. 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 a.m., Nurse Joann Green called and reported that at 5:30 a.m. 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 writing "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 client. 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 and arrival, and details of treatment. However, do not mention in the client’s record that an incident report or occurrence report was filled out.
Always document a client’s uncooperative behavior. For example;
- Leaving against medical advice,
- Refusing or abusing medications,
- Failing to follow diet or exercise plan,
- Refusing to follow instructions to stay in bed or ask for assistance,
- Failing to give information that effects care such as complete history, current medication, treatments,
- Patient or family tampering with traction, IV’s, 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 you are taking to protect your client (e.g., night light left on, call light available, floor clear of trip hazards, etc.).
Chart that the facility’s safekeeping for valuable possessions system was explained and made available to the client. Encourage the client or family members to send any possessions home. If they agree, have them sign their names next to a documented statement to that effect. Discuss the availability of a safe and make sure that all items put in the safe are recorded on a receipt complete with the client’s name and ID number. Describe each item in detail using objective language. For example, yellow ring with clear stone instead of charting a gold diamond ring. Update the list of valuables frequently for long-term clients. Before a client is transferred, take an inventory of the valuables list to verify location of items.
Document medication administration as thoroughly as possible. Note the date, time, your initials, the method of administration, and the site where the medication was given if it is an injection. 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 along with the type and size of the catheter.
If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the medication. 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 client medication while you are off the unit, make sure that person charts that he or she administered the medication.
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:
- 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