Practical Tips for Documentation

• Be sure you are documenting in the correct patient record.
• Strive to produce documentation that reflects the nursing process and full scope of nursing practice; include actual work of nurses, including education, physical, and psychosocial support.
  • Vital signs, pain scoring, any change in patient’s condition, medications, treatments, interventions, and reassessments.
  • All patient teaching, including preoperative, postoperative, and discharge instructions, who was present, and the content provided; document that the patient understands what has been presented and that the patient was given the opportunity to ask questions.
• Document accurate and complete descriptions.
• Provide complete medication administration documentation and patient response.
• Record details of phone calls or messages to provider and response; include date and time.
• Document preventative measures, such as falls risk identification bands and signage.
• Document patient refusal and/or compliance with medical care or medications, along with notification to provider.
• Document events/care in timely manner.
• Clearly note if documentation is post-facto with details of date and time. Never document ahead of time.
• When documenting a symptom, follow with implementation of treatment/intervention and patient response.
• When necessary to document statements that are verbalized by someone, always use quotation marks.  
• Do not alter the medical record.
• Document the whole story, but in a concise manner.
• Satisfy legal requirements:
  • Each page of the medical record (electronic or written) must include the patient’s name and medical record number.
  • All entries in the record must be signed, dated, and timed accurately
    • Include original signature, full name, and professional title (or electronic signature if electronic health record used)
    • Include current date, month, year, and time (either a.m./p.m. or military time) immediately before, during, and after adverse events or when notifying another caregiver that a problem exists
  • Incorrect entries must be identified clearly.
    • Electronic health records have specific pathways for correcting errors. Be familiar with the correction procedures for each system used within your institution.
• Document the use of a healthcare interpreter or interpretation service if utilized. If a family member or a non-healthcare personnel is used as an interpreter, document the patient’s approval and the name of the person interpreting.
• Always document the patient’s baseline mental status.
• Always assess the patient at the time of discharge or transfer; it is important to know the status of a patient before and after your care.
• Document that the patient and family members (if consent from patient) were informed of the patient’s condition, treatment, progress, and self-care recommendations.
• Avoid words such as accidentally, assume, confusing, could be, may be, miscalculated, mistake, unintentionally, inadvertently, unexpectedly, appeared, apparently, and seems to be.
• Never document an acute abnormality found during physical exam without documenting the intervention initiated, and never document the intervention initiated without documenting the evaluation/response of the patient.
• Never document a body system abnormality without details, as the abnormality or deficit may worsen over time.
• Use quantifiable data with descriptions for wounds (measurements for depth, etc.).
• Don’t document for another health care provider or sign off on another practitioner’s interventions.
• Don’t correct or destroy a colleague’s notes.