Documentation Do’s and Don’ts
Name
Class
Period
Date
Do you know the strengths and weaknesses of your documentation format? You have to make
sure that it’s complete, correct and timely. If it’s not, it could be used against you in a lawsuit.
After reading each documentation practice, circle whether it is a documentation “do” or “don’t.”
1.
DO/DON’T
Write legibly.
2.
DO/DON’T
Document often enough to tell the whole story.
3.
DO/DON’T
Chart patient care at the time you provide it.
4.
DO/DON’T
In order to provide the whole picture, write descriptions such as "bed soaked" or "a
large amount."
5.
DO/DON’T
Chart the time you gave a medication, the administration route, and the patient's
response.
6.
DO/DON’T
It is ok to chart a symptom, such as "c/o pain," without also charting what you did
about it.
7.
DO/DON’T
In order to save time, it is ok to chart care ahead of time—even though something
may happen and you may be unable to actually give the care you've charted.
8.
DO/DON’T
Chart a patient's refusal to allow a treatment or take a medication. Be sure to report
this to your manager and the patient's physician.
9.
DO/DON’T
If necessary, give explanations such as "Medication not given because not available."
10.
DO/DON’T
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.
11.
DO/DON’T
Record each phone call to a physician, including the exact time, message, and
response.
12.
DO/DON’T
Sometimes it is ok to alter a patient's record.
13.
DO/DON’T
Chart precautions or preventive measures used, such as bed rails.
14.
DO/DON’T
Check that you have the correct chart before you begin writing.
15.
DO/DON’T
In the event that it is critical to chart what someone else said, heard, felt, or smelled,
use quotations and attribute the remarks appropriately.
16.
DO/DON’T
Make sure your documentation reflects the nursing process and your professional
capabilities.
Documentation Do’s and Don’ts
Answer Key
1.
DO
Write legibly.
2.
DO
Document often enough to tell the whole story.
3.
DO
Chart patient care at the time you provide it.
4.
DON’T
Don't write imprecise descriptions, such as "bed soaked" or "a large amount."
5.
DO
Chart the time you gave a medication, the administration route, and the patient's
response.
6.
DON’T
Don't chart a symptom, such as "c/o pain," without also charting what you did about
it.
7.
DON’T
Don't chart care ahead of time--something may happen and you may be unable to
actually give the care you've charted. Charting care that you haven't done is
considered fraud.
8.
DO
Chart a patient's refusal to allow a treatment or take a medication. Be sure to report
this to your manager and the patient's physician.
9.
DON’T
Don't give excuses, such as "Medication not given because not available."
10.
DO
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.
11.
DO
Record each phone call to a physician, including the exact time, message, and
response.
12.
DON’T
Don't alter a patient's record--this is a criminal offense.
13.
DO
Chart precautions or preventive measures used, such as bed rails.
14.
DO
Check that you have the correct chart before you begin writing.
15.
DON’T
Don't chart what someone else said, heard, felt, or smelled unless the information is
critical. In that case, use quotations and attribute the remarks appropriately.
16.
DO
Make sure your documentation reflects the nursing process and your professional
capabilities.