Can You Make Documentation Easier for Me?
I can sure try to make it easier for you to document. How about Do's and Don'ts for Charting (NSO Newletter, Spring, '98). Let's do the Do's first, okay?
The Do's That Make Charting Easier
Check that you have the correct chart before you begin writing.
Make sure your documentation reflects the nursing process and your professional capabilities.
Write legibly.
Use a permanent black ink pen...other colors do not Xerox well.
Chart completely, concisely and accurately ("Tell it like it is.")
- Write clear sentences that get right to the point.
- Use simple, precise words.
- Don't be afraid to use the word "I."
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More Do's to Make Charting Easier
Chart the time you gave a medication, the route you gave it and the client's response.
Chart precautions or preventive measures used, such as bed rails.
Include the following information when documenting nursing procedures:
- What procedure was performed
- When it was performed
- Who performed it
- How it was performed
- How well the client tolerated it
- Adverse reactions to the procedure, if any (Charting Made Incredibly Easy, 2002, p. 286)
Record each phone call to or from a physician, including the exact time, message, and response (use that phone log we just talked about earlier).
Chart what you feel is important data from visits by physicians or other members of the health care team such as the dietician, social worker, etc.
Chart as soon as possible after giving care; don't wait to chart until the end of your work day.
Chart a client's refusal to allow a treatment or take a medication. Be sure to report this to your immediate supervisor and the client's physician.
Chart client's subjective data (what the client perceives and the way they express it) by directly quoting it. This is the one time you can use quotation marks.
If you don't give a medication, circle the time and document the reason for the omission.
If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry.
If information on a form such as a flow sheet doesn't apply to your client, write NA (not applicable) in the space provided.
Chart often enough to tell the whole story.
Use only commonly used or approved abbreviations and symbols (Kozier, et al. Clinical Companion, 1998, p.200).
Document discharge instructions including any referrals to home health agencies and other community providers as well as any patient teaching that was done.
Post a list of commonly misspelled words or confusing words, especially terms and medications, regularly used in your work setting. Remember many medications have similar names but very different actions.
When documentation continues from one page to the next, sign the bottom of the first page. At the top of the next page, write the date, time and "continued from previous page." Make sure each page is stamped with the client's identifying information.
The Dont's of Charting
Don't chart a symptom, such as "c/o pain," without also charting what you did about it.
Don't alter a client's record...this is a criminal offense. Here are the four (4) don'ts or "red flags" of chart altering that are to be avoided:
- Don't add information at a later date without indicating that you did so.
- Don't date the entry so that it appears to have been written at an earlier time.
- Don't add inaccurate information.
- Don't destroy records.
Don't use shorthand or abbreviations that aren't widely accepted or at least not accepted in your facility. If you can't remember the acceptable abbreviation, then write out the term.
Don't write vague descriptions, such as "drainage on bed" or "a large amount."
Don't give excuses, such as "Medicines not given because not available."
Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and give credit to the individual who said or experienced it.
Don't chart your opinions.
Don't use language that suggests a negative attitude towards your client such as the words stubborn, drunk, weird, looney or nasty.
Don't be wishy-washy. Avoid using vague terms like "appears to be" or "apparently" which make it seem as though you are not sure what you are describing or doing.
Don't chart ahead of time...something may happen and you may be unable to actually give the care that you've charted. And that goes for charting care given by others...don't do it.
Notes filled with misspelled words and incorrect grammar are as bad as those done in illegible handwriting. Information may be misunderstood if such notes end up in a court room.
Don't record staffing problems.
Don't record staff conflicts.
Don't document casual conversations with your colleagues.
______________________________________________ Charting care that you haven't done is considered fraud.
______________________________________________
Hold on, there's more! Here are a few other noteworthy Don'ts:
Don't use whiteout or an eraser...if you make a mistake, draw a single line 
through the entry and write "mistaken entry" rather than "error." The word error could seem to indicate that a mistake in care, not documentation, was made. Write in the correct entry as close to the mistaken entry as possible and sign with your first initial, last name and title (Eliopoulos, 1998, p, 71). Also writing "oops," "oh no" or "sorry" or drawing a happy or sad face anywhere on a record is unprofessional and inappropriate.
No empty lines or spaces... fill in the empty line or space with a single line to prevent charting by someone else (Kozier, et al. Clinical Companion, 1998, p. 200).
No writing in the margins.
No mention of any incident or accident report in the medical record ... document only the facts of an incident and never write the words "incident report" or indicate that you have filed one.
Don't use words associated with errors or ones that suggest that the patient's safety was in danger such as: "by mistake," "accidentally," "unintentionally," "miscalculated," "confusing."
Don't name a second patient … doing so violates that patient's confidentiality. If you have to refer to a second client, do so by using the word "roommate" or the room number.
