Sign Up
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Medical Documentation

2 Contact Hours
Listen to Audio
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Athletic Trainer (AT/AL), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Friday, September 19, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

CEUFast, Inc. is an AOTA Provider of professional development, Course approval ID#03292. This distant learning-independent format is offered at 0.2 CEUs Intermediate, Categories: Professional Issues. AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9757.

CEUFast, Inc. (BOC AP#: P10067) is approved by the Board of Certification, Inc. to provide education to Athletic Trainers (ATs).

FPTA Approval: CE24-1116772. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.

≥92% of participants will have improved knowledge of medical record documentation requirements and professional, responsible documentation strategies.


At the completion of this course, the participant will be able to:

  1. Identify at least one Joint Commission documentation guideline.
  2. List four abbreviations listed on the Joint Commission’s “do not use” abbreviation list.
  3. Describe two different documentation styles.
  4. Identify three progress note formats.
  5. Apply two strategies to avoid legal problems with documentation.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
  • 0% complete
Hide Outline
Playback Speed

Narrator Preference

(Automatically scroll to related sections.)
Medical Documentation
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    David Tilton (RN, BSN)


We live in a measurement culture. Actions, observations, and intent are all subject to review and comparison to desired standards. Records must be generated, stored, and maintained to meet internal and external pressures in our profession. Medical documentation has become a component of health care as significant as the rendering of firsthand, direct person intervention. Improving our knowledge of documentation premise and process is essential to hone our professional technical skills.

The Health Record

Medical documentation refers to any written or electronically generated information about a client describing services or care provided to that client. Documentation may be in the form of paper records or electronic documents. Electronic documents include copies of handwritten care documents, computer-created medical record files, faxes, e-mails, pictures, and video or audio recordings. Through documentation, key observations, decisions, actions, and outcomes can be communicated and preserved in a lasting fashion. Documentation intends to create a permanent, accurate account of what occurred and when it occurred.

Today's challenge is to provide succinct but comprehensive documents that accurately portray the client's experience while addressing professional and organizational care standards, regulatory requirements, fiscal responsibility, and criteria for reimbursement. This record of care, a legal document, includes information from health professionals whose interdisciplinary function has contributed to client outcomes.

With the abundance of information sources in health care’s data-rich environment, defining exactly what elements comprise the legal health record is essential. Guidelines from AHIMA, the American Health Information Management Association, suggest that each organization be responsible for defining the content of its legal health record according to its system capabilities and legal environment (Medical Record Review, 2023).

The passage of the Patient Protection and Affordable Care Act (ACA) of 2010 (Fletcher, 2022) makes it mandatory for each healthcare facility to have a secure compliance system. Each compliance system must be able to guide and ensure an accurate and complete record generation (e.g., documentation), record maintenance, and records destruction (when appropriate). The American Health Care Association (AHCA) guides facilities in designing compliance programs. In their recommendations concerning creating and retaining records, AHCA and AHIMA list the need for each facility rendering health care to address the following items.

  • Maintenance of records and information in a safe, secure place.
  • Routinely creating and maintaining hard copies of electronic documentation.
  • Limiting access to records to prevent fabrication or destruction.
  • Development of document retention and destruction policies consistent with applicable laws.

Legal health records must meet accepted standards within each organization and those applied by review or oversight authorities such as the Centers for Medicare and Medicaid Services, state and federal regulations, or the Joint Commission on Accreditation of Healthcare Organizations.

While organizations such as the Joint Commission recognize that physical (e.g., paper charts) and electronic health records must be individualized to each care facility's unique needs and settings, some essential components should uniformly be present (R&G Editorial Staff, 2022).

  • Client identifying information.
    • Name, birth date, residence, sex, blood type, etc.
  • Known medical history.
    • Medical, surgical, medication, family, allergies, social history, and immunizations.
  • Medical encounters.
    • Summations of interviews, assessments, and interventions by medical personnel such as physicians, specialists, and consultants.
  • Orders and Prescriptions.
    • Medical orders for specific treatments or medications.
  • Progress notes.
    • Documentation of observations or care given by all healthcare team members in chronological order leading to the client’s current state of health.
  • Test results.
    • Laboratory reports, imaging studies, pathology results, respiratory testing, etc.
  • Medical directives.
    • Medical or health care power of attorney or living will, etc.
  • Consent forms.
    • Including notes regarding informed consent, risks and benefits, and discussions concerning the probability of successful care.
  • Financial information.
    • Insurance information, occupation, relation to the responsible paying party, etc.
  • Other information.
    • Such items as flow sheets (i.e., Intake and Output, Vital Signs, etc.), Medication Administration records, ECG tracings, educational needs assessments, etc.

Communication of Information

Documentation in the legal medical record provides a means by which health professionals can communicate information to each other. Notes on what we observe and how we respond to interventions, or the formations of care plans, are entered into this repository of information centered upon the client.

Healthcare facilities are tasked by state and federal regulations, as well as organizations such as The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS), to effectively manage the collection of health information using uniform data sets and policies that guide record creation and handling. While the health record components may differ in each facility, specific minimum standards are expected for paper and electronic documentation systems.

External sources' suggestions can be specific, such as the medical abbreviation use standard (IM.02.02.01.EP.02 & 03) from the Joint Commission. In this standard (formerly known as NPSG.02.02.01), each hospital must have a written policy that addresses abbreviations and symbols. This policy addresses all orders and medication-related handwritten documentation (including free-text computer entry) or pre-printed forms (Sharma, 2023).

According to Tariq & Sharms, 2023, The Joint Commission has even declared that “completely removing dangerous medical abbreviations is a far better option than healthcare institutions undertaking secondary measures like quality control or restricting the use of only certain abbreviations.” 

The Joint Commission Information Management Chapter, Accreditation Standards: Hospital, Standard IM.02.02.01.EP.02 & 03 “Do Not Use” List (The Joint Commission, 2021).

Each hospital is to have a written policy that includes the following:

  • Terminology and definitions approved for use in the hospital.
  • Abbreviations, acronyms, symbols, and dose designations approved for use in the hospital.
  • Abbreviations, acronyms, symbols, and dose designations are prohibited in the hospital, which includes the following:
    • U, u
    • IU
    • QD, QD, q.d., qd
    • QOD, QOD, q.o.d, qod
    • MS, MSO4, MgSO4
    • Lack of leading zero (.X mg)
    • Trailing zero (X.0 mg)
      • Note: A trailing zero may be used when required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
Authors Note: The "Do Not Use" list is the standard for abbreviations, symbols, and dose designations identified as potentially dangerous or confusing and should be avoided to prevent medication errors. The list is intended to promote standardization and clarity in medical documentation. It pertains to handwritten medication notes or orders, the use of preprinted forms, and all forms of written medical documentation.

The Medical Professionals Reference website (MPR Staff, 2022) states that medical professionals of all disciplines should never include the following abbreviations in documentation.

AbbreviationsIntended MeaningMisinterpretation
ccCubic centimetersMistaken as “u” (units).
IU*International unit(s)Mistaken as “IV” (intravenous) or the number 10.
lLiterMistaken as the number 1.
mlMilliliterThe lowercase letter “l” is mistaken as the number 1.
MM or MMillionMistaken as “thousand.”
M or KThousandMistaken as “million.”
Ng or ngNanogramMistaken as “mg” or “nasogastric.”
U or u*Unit(s)Mistaken as 0 or 4.
μgMicrogramMistaken as “mg.”
AD, AS, AURight ear, left ear, each earMistaken as “OD, OS, OU” (right eye, left eye, each eye).
IJInjectionMistaken as “IV” or “intrajugular.
INIntranasalMistaken as “IM” (intramuscular) or “IV.”
ITIntrathecalMistaken as “intratracheal,” “intratumor,” “intratympanic,” or “inhalation therapy.”
OD, OS, OURight eye, left eye, each eyeMistaken as “AD, AS, AU” (right ear, left ear, each ear).
Per osBy mouth, orallyMistaken as “left eye” (OS).
SC, SQ, sq, or sub qSubcutaneous(ly)“SC” and “sc” are mistaken as “SL” or “sl” (sublingual).
SQ is mistaken as “5 every”; The “q” in “sub q” is mistaken as “every.”
HSHalf-strengthMistaken as “bedtime.”
hsAt bedtime, hours of sleepMistaken as “half-strength.”
o.d. or ODOnce dailyMistaken as “right eye” (OD), leading to oral liquid medications given in the eye.
Q.D., QD, q.d., or qd*Every dayMistaken as q.i.d. (four times daily).
QhsNightly at bedtimeMistaken as “qhr” (every hour)
QnNightly or at bedtimeMistaken as “qh” (every hour).
Q.O.D., QOD, q.o.d., or qod*Every other dayMistaken as “qd” (daily) or “qid” (four times daily).
q1dDailyMistaken as “qid” (four times daily).
q6PM, etc.Every evening at 6 PMMistaken as “every 6 hours”.
SSRISliding scale regular insulinMistaken as selective serotonin reuptake inhibitor.
SSISliding scale insulinMistaken as Strong Solution of Iodine (e.g., Lugol’s).
TIW or tiwThree times a weekMistaken as “3 times a day” or “twice in a week.”
BIW or biwTwo times a weekMistaken as “2 times a day”.
UDAs directed (ut dictum)Mistaken as unit dose (e.g., order of “diltiazem infusion UD” mistakenly given as a unit [bolus] dose).
D/CDischarge or discontinuePremature discontinuation of medications if D/C (intended to mean “discharge”) is mistaken as “discontinued” on a medication list.
OJOrange juiceMistaken as “OD or OS” (right or left eye).
Period following abbreviations (e.g., mg., mL.)mg or mLUnnecessary period mistaken as the number 1, especially if written poorly.
SS or ssSingle strength, sliding scale (insulin), signs and symptoms, or ½ (apothecary)Mistaken for each other or the number “55”.
(MPR Staff, 2022)

Communicating Clearly in Chart Notes

The knowledge base offered within various healthcare professions is full of practical help. Allied health professionals, such as medical information management specialists, provide significant insight into documentation perception by those reading it and what is and is not the best phrasing. Widespread practice experience leads to acceptable manners for consistently handling and conveying information.

Documentation Do’sDocumentation Don’ts
  • Be timely with chart notes.
  • Be accurate with information.
  • Be complete in what you write.
  • Be legible.
  • Be objective and provide facts.
  • Be clear about pertinent negative findings.
  • Be observant in reporting unusual interactions between clients and others.
  • Be correct in spelling, grammar, and use of approved abbreviations.
  • Be sure client identifying information is on each page of the written chart.
  • Avoid criticism or opinions.
  • Avoid erasing or obliterating unwanted chart entries.
  • Avoid gaps in your written notes.
  • Avoid sarcasm, slurs, use of humor, and profanity.
  • Avoid drawing conclusions – give facts instead.
  • Avoid removing parts of the chart to work on elsewhere.
  • Avoid asking others to document for you.
  • Avoid documenting for others.
  • Avoid mentioning incident reports within the client chart.
(SafetyCulture Staff, 2023) (Tomaselli, 2022)

Progress notes are essential legal, medical records based on the healthcare professional process: assessment, professional diagnosis, planning with goal setting, implementation/ interventions, and evaluation. Progress notes serve, too.

  • Establish a communicated baseline.
  • Record relevant data at regular intervals.
  • Provide snap-shot summaries of a client’s condition.
  • Document changes in condition.
  • Document response, or lack of response, to treatment.

Each care setting tends to specify the patient data format or chart note style that they prefer for clinical notes. Follow your facility’s documentation policies. There are a multitude of charting styles currently available. Each notation format has advantages as well as disadvantages. Certain formats have been around for a long time, while others are new. Many institutions blend two or more format systems to get the right record-keeping style that suits their unique needs. Whichever style finds favor in your setting, clearly communicate while avoiding potential legal problems. Careful forethought and practice using a charting strategy will consistently provide clear and legally defensible documentation.


The narrative note is the most traditional medical record progress note style. This style chronologically documents assessment data, interventions, and patient responses with a free-flowing structure, content, and form. Numerous health facilities rely solely on this format, while narrative notes supplement check-off forms and flow sheets in other settings (Brown, 2023).

Narrative charting tends to be thorough and detailed. It is also time-consuming. The chronological narrative is popular with healthcare professionals who document complex descriptions with comprehensive assessments.

One critical legal issue with this style is that shift to shift, person to person, inconsistency makes it difficult to follow the patient's progress and plan appropriate care. Each provider may write their notes with a unique style, thus making continuity of care more difficult. Since this form allows for "free-flowing" paragraphs, there is more room for sloppy writing, spelling errors, rambling, repetitive narration, inappropriate subjective opinions, and inaccurate language. Although these problems do not necessarily indicate negligence, a negative inference may occur regarding the "professionalism" of the provider and the facility.

To avoid problems, ensure that each provider tries to achieve consistency with record keeping. Decisions can be made regarding the placement of vital signs, patient outcomes, and care rendered within each narrative paragraph. Turn critical thinking into critical charting. Have a dictionary available to help with spelling problems. Handwriting must be legible, and descriptions of patient observations must be precise. When flow charts accompany narratives, documenting vital signs, for example, avoid repeating that information in the narrative unless there is a specific change that you are addressing in the note.

Problem-Oriented Medical Records

Problem area charting formats focus on specific needs rather than general assessment information (Sanchezz, 2022). POMR or problem-oriented medical record systems frequently use acronyms to provide memory aids for the written progress note structure. As POMR documentation focuses on progress in specific problem areas, medical records professionals generically refer to POMR as focus charting.

All POMR methods contain combinations of four key components.

  1. Collecting information to provide a baseline for identifying improvement or decline.
  2. Creating a problem list of active client issues and past resolved problems.
  3. A form of problem management plan.
  4. Records of each client encounter, structured around problem areas followed with the client.

POMR problem-oriented charting acronyms

  • SOAP – Subjective, Objective, Assessment, Plan
  • SOAPIER – Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision
  • APIE – Assessment, Plan, Intervention, Evaluation
  • DAPE - Data, Assessment, Plan, Evaluation
  • DARE – Data, Assessment, Response, Education
  • DARP – Data, Assessment or Action, Response, Plan

We will now look at examples of POMR format charting as they move along a continuum away from straight narrative documentation.


SOAP charting follows a distinct format that defines the various sources of information followed by an intervention plan. SOAP stands for subjective, objective, assessment, and plan.

  • Subjective - provides the client’s condition in a narrative form using that person’s own words to describe their condition and concerns.
  • Objective - relates findings such as vital signs, observations from physical examination, laboratory results, and measurements (weight, age, and so on).
  • Assessment - summarizes findings into a professional observation of the condition, such as found within the medical or nursing diagnosis system.
  • Plan - details what the healthcare professional will do to address the client’s needs.


The basic SOAP format for progress notes may be expanded to fit unique organizational needs, such as:

  • Intervention - details specific to interventions formulated in the earlier SOAP system.
  • Evaluation - of outcomes from the plan of care.
  • Revision - of planned care needed based on the evaluation following the intervention.


DARP moves further along the continuum away from straight narrative-chronological charting into a combination of check-off forms and flow sheets supplemented with narrative progress notes. The POMR style progress note often follows the DAR(P) format.

  • Data - gathered is related to a focus issue (e.g., often a summary referring to the information found on a checklist or flowsheet).
  • Assessment - of the data with additional information not related to the flowsheet (NOTE: Action may be substituted as a keyword here or integrated into the Assessment phase).
  • Response - to the need brought into focus during the assessment of available data.
  • Plan - for continuing care following the intervention phase of the response (i.e., a continuation of observation, education of client, notification of another professional, etc.).

With this charting style, risk management strategies must ensure that healthcare professionals from the unit where the forms will be utilized have input into the check-off forms and flowsheets. Ample room must be present to record pertinent information. Each institution should provide the staff with sufficient training to utilize the strengths of this system to its best advantage.

CBE - Charting by Exception

Many professionals consider charting by exception (CBE) the antithesis of narrative progress notes. CBE is a format developed to overcome the recurring frustration of lengthy, repetitive narratives. It consists of a heavy component of flowsheet documentation with a blending of POMR narrative added. Quickly marked checklists and flowsheets document normal assessment findings and routine care with narrative documentation limited to findings outside the norm.

One advantage is that flowsheet design can incorporate clearly defined expectations for the type of patients cared for in each unit and each care setting. Standardizing the forms process within each facility allows caregivers to provide consistent patient assessment and documentation. The CBE system still requires POMR documentation of significant or abnormal findings yet does not require narrative noting when expected outcomes are achieved by the interventions provided. Charting by exception can reduce the amount of time spent on documentation.

Charting by exception has the potential to be a great asset to electronic medical records documentation. Using quickly scored checklists that document routine matters complements at-the-bedside computerized data entry. CBE may be at the forefront of medical documentation by shifting the emphasis from descriptive discursive narrative paragraphs for every routine and expected event to minimal narrative notes for only unexpected or highly noteworthy events.

Since charting by exception is a departure from more traditional medical documentation models, it can lead to legal challenges. The biggest problem noted seems to be the appearance of significant gaps in time without patient contact. Although this is not true, no notes will appear in the record to prove the nurse's attentiveness if no significant observations are made. Likewise, wellness promotion and preventive care may not be a component of a patient problem checklist, preventing full credit for the work done.

Clinical Pathways

Clinical pathways (aka care pathways, critical pathways, care maps, or integrated care pathways) are multidisciplinary descriptions of the expected care for a specific illness or condition with a specified timeline for the anticipated length of stay. The pathway focuses on outcomes and efficient use of resources while still providing quality care. Pathways have proven to be an effective way to identify variances from expected outcomes and promote efficiently organized care centered on evidence-based practice.

Typically, pathways created address a specific condition. It usually includes the expected length of stay, care setting, timeline, assessment, multidisciplinary interventions, patient activity, medications, lab testing, patient and family education, and outcomes. Some facilities are using clinical pathways in conjunction with charting by exception. The use of pathways is changing documentation in healthcare settings. Managed care, for example, is heavily invested in clinical pathways, recognizing them as a valuable tool for rendering and documenting quality care.

The primary focus on avoiding legal complications in clinical pathways is understanding how your facility uses them and what supportive documentation must accompany them. In certain facilities, the pathway has replaced the traditional care plan and progress notes with documentation made directly onto the pathway document unless the patient does not meet the outcome. At this point, a narrative note should be written.

Computerized Records

Software programs are available to capture client data in a computerized format. Depending upon the system the facility selects, information may be entered by keyboard, voice activation, mouse, touch-sensitive screen, or a combination of these methods. Some systems allow the healthcare professional to select pre-written phrases to describe the patient's condition with little sentence formation performed by the professional.

The Fear Factor in Electronic Health Records (EHR) Technology

In discussions among healthcare professionals, concerns about electronic medical health records often focus more on the system's mechanics, availability, and security than documentation format styles. At heart, fears revolve around three points commonly cited: confidentiality, integrity, and availability, often referred to as the “CIA” properties of computer documentation.

  • Confidentiality demands that no unauthorized party may access sensitive information.
  • Integrity requires that unauthorized parties or technical errors cannot alter information.
  • Availability demands that sensitive services always remain available.

Annual client record data breaches exceed 6.5 billion U.S. healthcare dollars (Basil et al., 2022).

Comprehensive education must be provided before implementing a computerized system. A "hard copy" of essential information should be printed at designated times to ensure an accurate record in case of computer problems, as determined by each facility’s policy. Error correction must be completed before the information is permanently stored, and all information should be double-checked before entering it. Any corrections made after storage will have to be specially noted.

Remember the basics of HIPAA training related to electronic medical documentation.

  • Never leave a computer terminal unattended after you have logged in.
  • Do not leave information about a client on the screen where others can view the monitor.
  • Never give your password or computer signature to anyone.
  • Tell a supervisor if you suspect someone may have used your code.

Legally Defensible Charting

Specific guidelines apply regardless of the documentation format you use. The following tips will help defend your record-keeping in the courtroom. Be careful not to disregard good paper and pen charting practice. Paper charting is the standard to which electronic documentation strives to equal.

Legibility and grammar are essential. Never second-guess someone else’s handwriting or their intent. 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 available to everyone responsible for charting and post a list of commonly misspelled words. Avoid abbreviations when possible. If you must use them, use only abbreviations approved by your facility.

Make sure you have the CORRECT CHART before you begin writing.

The medical record is a permanent legal "business record," 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 records, for example, to note discontinued medication, make sure that your medical records department can effectively copy highlighted information. Certain brands or styles of copy machines "gray out" any writing covered by a highlighter.

If anything needs to be secured into the medical record with tape (monitor strips, blood product labels, or other essential items), use double-sided tape or tape only onto blank paper. Even though the tape is transparent and can be read by the naked eye, a copy machine may "blackout" the taped area. Faxes must be copied prior to inclusion in the chart. Unless you have a plain paper copying fax, the ink on the fax may be water-soluble and fade in days.

EVERY PAGE of the record must have a date and patient name. This notation is required for a record to be admitted in a courtroom.

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 when the entry is being added or when the observation occurred.

Avoid block charting, such as “11:00 pm to 7:00 am.” This type of documentation gives the impression of vagueness. Note exact times of all necessary 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 requires that the initial assessment and care plan be performed and documented by a registered nurse. Documentation by the proper person is critical in educational, nutritional, and rehab assessments.

Avoid documentation practices that 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 when caring for a patient.

To correct an entry, put a single line through the error, add your initials and correction date. 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 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 possible care and that the chart reflects respect for all healthcare team members.

Chart as soon as possible after seeing something or providing care. This timeliness helps eliminate the chance of forgetting essential data. Late entries, out-of-sequence entries, or addendum entries may sometimes be necessary. If the entry is made on 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 misunderstandings.

  • 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 document 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 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 entries such as “perhaps,” “maybe,” or “I think.”

Be careful to avoid labeling the patient. For example, avoid descriptions 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 client injuries need documenting. Objectively record what you witness without making any conclusions or unsubstantiated assumptions. Document comments from the patient, roommate, or visitor using quotation marks. Record the client’s vital signs, physical condition, mental condition, subjective complaints, physician’s notification and arrival, and treatment details. However, do not mention that an incident or occurrence report was completed.

Always document a client’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, and treatments.
  • Patient or family tampering with traction, IVs, and monitors.
  • Failing to follow up with visits to the clinic or physician.
  • Bringing unauthorized items into the facility.

Document any safeguards or other preventive measures provided to protect your patient (e.g., night light left on, call light available, floor clear of trip hazards, etc.).

Ensure the chart shows that the facility’s safekeeping for valuable possessions system was explained and made available to the client. Encourage patients and families to have possessions sent 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 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, a yellow ring with a clear stone instead of charting a gold diamond ring. Frequently update the list of valuables for long-term patients. Before a client is transferred, take an inventory of the list of valuables to verify the location of the items.

Document medication administration in as thorough a manner as possible. Note the date, time, your initials, method of administration, and the site where the medication was given if it is an injection. When recording intravenous (IV) infusions, note the infusion site, type and amount of fluid, medications added, and administration rate. 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.” Tactfully document your conversation with the doctor if a medication order is questioned. If someone else is giving your patient medication, ensure that the person charts that they administered it.

Neither the Centers for Medicare & Medicaid Services (CMS) nor The Joint Commission (TJC) prohibit verbal orders (AMA Staff, 2023). It would be best to avoid verbal and telephone orders when possible because of the elevated risk of errors. However, 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.

Read Back Rule

Whether electronic or handwritten, documentation of telephone orders, verbal orders, and the reporting of critical test results by either voice or phone fall under The Joint Commission’s “Read-Back” requirement (Paine & Benator, 2023).

Clarity and confirmation that the receiving person has received and written precisely what was intended is the purpose of read-back. Implementation is exactly how it sounds. Read back the order and get confirmation from the person who gave the order.

Documentation that read-back has occurred should follow the policy set by your facility. Generally, the notation T.O./R.B. and your signature are acceptable, although your place of employment may require that “telephone order read back” or “verbal order read back” be written out.

Documentation of discharge instructions should include diet, activity, medications (name, reason for taking, dosage, and frequency), skincare hygiene, specific treatments, follow-up appointments, and any agency referrals. Along with the note relating that instructions were given, document the patient and family’s comprehension of the discharge instructions. If any skills were demonstrated, record the patient’s ability to demonstrate in return what was taught.

Case Study

Situation: At 2:00 am, on night shift rounds, nurse Sally Rise, LPN, noticed the client being treated for a UTI and chronic liver disease with a bloody area on her bed linen from her left forearm where a heparin lock had been placed for IV antibiotics. The 62-year-old client, Rehma Fitzgerald, rouses quickly and knows where she is. She states being itchy and must have scratched it out.
SOAP Note:
  • Subjective – What did the client say?
  • Objective – What is observed?
  • Assessment – What do you assess as going on?
  • Plan – How will the situation be managed?
8/1/2019 0200 Ms. Fitzgerald states, “Oh dear, I must have pulled that fluid tube device out when I scratched. I have been so itchy!” A six cm area of damp blood was on the bed covers beside the client's left forearm. Left forearm heparin lock was found pulled out of the skin, dangling from opposite dressing remnants—no visible hematoma. The client unintentionally pulled the heparin lock out due to skin irritation at the site. The pressure was held at the bleeding site for three minutes to ensure clotting. The site was cleansed with betadine swipe and band-aide applied. Linen changed. IV team will be contacted to resume IV access. A note will be left for the physician informing her of the incident and requesting prn anti-itch medication. -------------------- S. Rise LPN
DAR Note:
  • Data – Subjective and objective.
  • Action – What staff said and did.
  • Response – What the client said and did.
8/1/2019 0200 L. forearm heparin lock found DC’d by the client. No visible hematoma. 6cm damp blood drainage on bed linen. The client stated had been itching and must have scratched the device out. Site cleaned; pressure held 3min. The light dressing was applied. IV team and MD to be informed. Anti-itch prn will be requested. The client states, “Thank you, dear. I must have scratched that device out. I have been so itchy!” ----- S. Rise LPN


The primary purpose of all medical documentation is to establish an individual’s health status and the need for care, record the care given, and demonstrate the care results. Medical documentation allows for the exchange of information between all healthcare team members. The health record provides legal proof of the type of care the patient received and that person’s response to that care. Medical documentation that is poorly maintained, incomplete, inaccurate, illegible, or altered generates doubt regarding the treatment given to the patient. Be factual when documenting. Do not guess, generalize, or give individual opinions. Rely on your professionally guided physical observations. What did you see, feel, hear, or smell? Documentation of patient care holds the healthcare team members to professional accountability and demonstrates the quality of care you have given.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
No TestDescribe how this course will impact your practice.

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


  • AMA Staff. (2023, January 26). Are Verbal Orders Prohibited? American Medical Association. Visit Source.
  • Basil, N. N., Ambe, S., Ekhator, C., & Fonkem, E. (2022, October 14). Health Records Database and Inherent Security Concerns: A Review of the Literature. Visit Source.
  • Brown, M. (2023, May 20). How to Chart as a Nurse: Nursing Charting. Nursing Troop. Visit Source.
  • Fletcher, T. (2022, July 8). Is a Compliance Plan Mandatory for Healthcare Providers? NAMAS. Visit Source.
  • Medical Record Review. (2023, May 23). The Legal Health Record – Its Components, Significance & Some Considerations. MOS Medical Record Review. Visit Source.
  • MPR Staff. (2022, September 19). Error-Prone Abbreviations. MPR Medical Professionals Reference. Visit Source.
  • Paine, S. J., & Benator, S. G. (2023, July 7). JCAHO Initiative Seeks to Improve Patient Safety. Medscape. Visit Source.
  • R&G Editorial Staff. (2022, August 24). Components of a Medical Record. R&G Medical Legal Solutions. Visit Source.
  • SafetyCulture Staff. (2023, January 23). Good Documentation Practices: Recordkeeping Rules That Everyone Should Follow. Safety Culture. Visit Source.
  • Sanchezz, B. (2022, August 29). Which of the following best describe the major components of the problem-oriented medical record? Sybrid MD. Visit Source.
  • Sharma, S. (2023, May 22). Inappropriate Medical Abbreviations. National Library of Medicine. Visit Source.
  • Tariq, R. A., & Sharms, S. (2023, May 22). Inappropriate Medical Abbreviations. NIH National Library of Medicine. Visit Source.
  • The Joint Commission. (2021, September 17). Official "Do Not Use" List. The Joint Commission Fact Sheet. Visit Source.
  • Tomaselli, J. (2022, November 3). How to Write Great Nurses’ Notes. Berxi. Visit Source