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't's for Charting (NSO, 2020).

The Do's That Make Charting Easier

Example of Both Incorrect and Correct Nursing Note Documentation

Wrong Way: Communication with patient's family begun today to specify the manner in which his condition is progressing and suggest a probable consequence of that progression.

Right Way: I contacted Mr. Boondoogle's wife at 1415 hours. I explained that his cardiac status was worsening and that he was being prepared for a cardiac catheterization procedure scheduled for 1600 hours.

More Do's to Make Charting Easier

  • 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, 2012, p. 286)

The Don't's of Charting

  • 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.

Charting care that you have not done is considered fraud.

Hold on, there's more! Here are a few other noteworthy don't's:

Don't use whiteout or an eraser.