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 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 kept available to anyone 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 record, perhaps to note discontinued medication, make certain that your medical records department can effectively copy highlighted information. Some copy machines "gray out" any writing covered by a 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 "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 a matter of days.
EVERY PAGE of the record must have the date and patient name. This notation 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 the entry is being added or the time that the observation took place.
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 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 rehab assessments.
Avoid documentation practices that 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 when caring for a patient.
To correct entries, put a single line through the error and 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 an 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 that 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 timeliness 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 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 (Small & Rutherford, 2009):
- 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 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 like 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 patient 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 patient’s vital signs, physical condition, mental condition, subjective complaints, physician’s notification and arrival, and treatment details. However, do not mention 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 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, treatments
- Patient or family tampering with traction, IVs, 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 you are taking to protect your patient (e.g., night light left on, call light available, floor clear of trip hazards, etc.).
The chart that the facility’s safekeeping for valuable possessions system was explained and made available to the patient. Encourage patient/family 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 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, 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 patient is transferred, take an inventory of the list of valuables to verify the location of items.
Document medication administration in as thorough a manner 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. When recording intravenous (IV) infusions, note the infusion site, type and amount of fluid, medications added, and the 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.” If a medication order is questioned, tactfully document your conversation with the doctor. If someone else is giving your patient medication while off the unit, make sure that person charts that they administered the medication.
Avoid verbal and telephone orders when possible because of the high 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 (Moghaddasi, et al.. 2017).
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.
Clarity and confirmation that the receiving person has received and written exactly 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. In general, 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.