Tips for Great Nursing Documentation

Clip board with stethoscope and pen

As the primary point of contact for patients, nurses have a great deal of responsibility when it comes to documenting patient care. Nursing documentation is important for both practical and legal reasons. Improper documentation can open up an employer to liability and malpractice lawsuits, while proper nursing documentation helps prevent medical errors and promotes the delivery of high-quality patient care.

Nursing Documentation Tips

The following tips, recommendations, and best practices can ensure your documentation is as precise and useful as possible.

Be Accurate.
Write down information accurately in real time. Inaccurate or misleading documentation is unethical and can harm patients.

Avoid Late Entries.
Late entries can introduce inaccuracies. If you have to document something after the fact, follow your employer’s late entry policy and clearly mark late entry notations.

Prioritize Legibility.
Others must be able to read your documentation without difficulty. In addition, legible writing improves your credibility and authority.

Use the Right Tools.
Nursing documents can be used in legal proceedings. For that reason, use only blue or black ink and never erase information from a nursing document; make a correction and initial it instead.

Follow Policy on Abbreviations.
When you use abbreviations, be sure they’re standard for your employer. Don’t use obscure or colloquial abbreviations, which can be confusing to other people reading your documentation.

Document Physician Consultations.
Document all parties consulted during patient care, including names, times, responses, and any resulting actions. This is critical in case a need or emergency arises.

Chart the Symptom and the Treatment.
Make sure you document both the symptom and the treatment you administered to address it.

Avoid Opinions and Hearsay.
Don’t write down opinions as facts. Use quotation marks to indicate an opinion and attribute the remarks to the correct person.

Common Nursing Documentation Errors

Common errors to avoid in nursing documentation include the following.

Medication or Allergy Omission.
Knowing what medications patients are taking and what they’re allergic to is critical to a doctor’s ability to administer the right treatment.. If a patient complains of a symptom, and that symptom is a side effect of a medication interaction introduced because the patient’s medications weren’t documented properly, it’s that much harder to narrow down what’s causing the symptom. Specify each medication administered, any permissions required, dosages, and patient reactions. Similarly, knowing that a patient is allergic to penicillin can be the difference between treating a simple infection with the right drug and creating more medical issues for the patient.

Blank Items on a Chart.
Blank spaces on a chart do more than fail to provide necessary information; they also create ambiguity. Was a space left blank because treatment wasn’t administered or because the nurse forgot to document the treatment that was administered? Blank spaces on charts can have legal ramifications, too. A patient who sues has a much stronger case if treatment wasn’t documented, even if it was provided; there’s no way to prove the treatment occurred.

Unclear Orders.
Just as you should never write unclear documentation, you should never accept orders you have questions about. If you disagree with or don’t understand an order, seek clarification. It’s better to take the extra time to understand what a patient’s treatment should be. When documenting orders, leave out the guesswork; ensure that you are conveying information as clearly and precisely as possible.

Improving Your Nursing Skills

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