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.