University:
Montgomery College
Course:
NURS 114: Professionalism and Communication in Nursing
Academic year:

2024
Views:

156

Pages:

1
Author:

Kasazami2c24

Do's & Don'ts of Documentation High quality documentation can protect nurses from accusations of malpractice and ensures the best care for patients. 1 Before entering anything, ensure the correct chart is being used 1 Don’t chart a symptom such as “c/o pain,” without also charting how it was treated 2 Ensure all documentation reflects the nursing process and the full extent of a nurse’s professional capabilities 2 Never alter a patient’s record - that is a criminal offense 3 Always use complete descriptions 3 Don't use shorthand or abbreviations that aren't widely accepted 4 Chart the time medication was administered, the administration route, and the patient response 4 Don't write imprecise descriptions, such as "bed soaked" or "a large amount" 5 Chart precautions or any preventative measures taken 5 Don't chart excuses, such as "Medication not administered because it wasn’t available" 6 Record any phone call to a physician, including the exact time, message, and response 6 Avoid charting what someone else said, heard, felt, or experienced unless the information is critical 7 Always document often enough and with enough detail to tell the entire story 7 Never chart care ahead of time, as situations often change and charting care that has not been performed is considered fraud Other charting do's include: Always detail the time and date of entry when making late chart updates and consistently notate patient refusal of medication or other treatment.