What to document
Good documentation includes charting in the following areas regardless of the
system (Narrative, Focus, or Charting by Exception) used for documentation.
1. Opening note: With in one (1) hour of assuming responsibility for care of the
client make an opening notation of the client’s general condition. I.e. awake,
alert, color good, resp even and regular. Nasal O2, @ 2 l/m per nasal cannula
2. Preset intervals: usually every two (2) hours in narrative charting in acute care
situations. It may be more frequently or less frequently depending on facility
policy and acuity of the client. Identify the client’s needs
3. Any Assessment information not documented on flow sheets
4. Any information reported to the doctor and the response
5. Client’s condition changes: If the client get better or worse or if there is not
change in reasonable amount of time it should be documented i.e. T. 99.2 º Skin
warm, dry cheeks not flushed. States, “I feel much better.”
6. New nursing diagnosis/problem identified. As soon as a new problem or
nursing diagnosis is identified, it should be recorded. This includes new
symptoms or behavior (Also what nursing interventions were instituted to deal
with the situation) i.e. +++ non pitting edema of ankles bilaterally. Feet elevated
on pillows.
7. Client Instruction: Client, family teaching, counseling, instructions given all
need to be documented even if the instruction is done during other care.
a. What was taught
b. Titles of handouts, models used, educational programs used
c. Include the client’s ability to do the care taught
d. Understands the information
e. Further teaching or reinforcement needed
f. How the teaching was evaluated
i.e. client and wife taught about low cholesterol diet. “Meal preparation for
low cholesterol” pamphlet used. Wife able to plan two meals satisfactorily.
8. Use of equipment and client’s response: Foley catheters, I.V.’s, oxygen, NG
tubes, drains, traction etc.
9. Procedures:
a. What you did
b. Supplies used
c. Effects of treatment
10. Pre-Procedure:
a. Vital signs
b. Completion of ordered prep i.e.4 ducolax tab taken
c. Effects of ordered prep i.e. Up to BR X3, stools watery, clear
d. Consent from signed
e. Emotional status or concerns of client. i.e. States “I don’t think I will get
through this.”
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11. Post-Procedure:
a. Time arrived back to unit
b. Condition on arrival
c. Use of any equipment/tubes
d. Education
e. Family present
f. Procedures or treatments started
i.e. returned from x-ray per stretcher. Color pink, resp even, regular, Foley
catheter patent, draining clear pale fluid. Husband at bedside.
12. Refusal of treatment:
a. Clearly document why the client is refusing
b. Your efforts to educate the client about the need for the treatment.
c. Risks of not having the treatment.
d. Communication of situation with physician/supervisor
e. Treatment not provided
i.e. States does not want to have surgery. Sates has decided the risks involve
are too great. Explained surgery will help XXXXXXX and XXXXX may
occur if not removed during the surgery. Supervisor notified. DR G.
Hammond notified. Consent form not signed. M. Tolliver R.N.
13. Withholding of treatments for other reasons. NPO for x-ray, medications
withheld.
14. Adverse reactions to medications or treatments
15. Client injury: Record the facts in the appropriate note. Do not document
incident report was filled out.
16. Occurrence of error
17. Unscheduled medications: One time orders, PRN medications, Stat orders.
These are documented in the nurse’s notes as well as the MAR
18. Spiritual interventions: Baptisms, last rites or other religious ceremonies.
Clergy do not have documentation privileges so nurses record for them.
19. Living will declarations.
20. Any attempt to reach the physician.
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Principles of charting

Entries must be made in black ballpoint ink (no felt tipped pens) or charted on the
computer

Each recording must be signed by the nurse making the recording. Signature
must include the first initial, legal last name and the nurse’s title. For students
S.N.
Example: G Finney, S.N.

An initial entry must be made with in one hour after assuming duty on the unit.
(This does not necessarily mean your thorough assessment) Example: 7:15 am
awake alert, sitting up in bed. Color pink.

Thorough assessments are expected for each client at the beginning of each
clinical day. The data must be pertinent to the client’s condition.

All records must be compete and accurate, consisting of facts and exact
observations rather than opinions or interpretations of an observation. Direct
client quotes may be used.

Explain in detail all abnormalities. i.e. reddened area on sacrum, describe what
you did for it, how big/little it is

Use only appropriate terminology and accepted abbreviations. If in doubt, spell it
out.

Records should be concise, organized and legible. They should also be in
chronological order.

Nursing diagnosis on care plans and interventions must be documented in the
nurse’s notes.

Record pertinent information, observations, and events concerning the client in
the appropriate place and sequence. (Only information that pertains to the client’s
health problems and care should be noted.)

When ever a problem is noted and charted – you must chart what you did abut the
problem.

Documentation of the date and time of each notation is essential. Record the time
assessments or procedures were done, regardless of the time the nurse actually
does the charting. For best practice record promptly.

The client’s name and the word client are omitted.

Record directly after carrying out a nursing intervention –Never before.

You may chart that something was done by another RN (or LPN) but usually each
nurse charts for him/her self. i.e. Dressing changed by J. Doe R.N.

When the client leaves from/returns to the unit, include time, destination, mode
and accompanying personnel.
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
The initial assessment and surgical checklist must be completed on the client
before he/she leaves for OR.

Frequencies of entries on nurse’s notes should be consistent with facility policy
and practice. Frequency of recording is primarily dependent upon client’s degree
of illness

Write a final note about the client’s condition at the end of the clinical day.

Good Charting:
o Individualized client assessment
o Equipment in use
o Identified nursing problems
o Specific nursing interventions’
o Evaluation of the effectiveness of nursing interventions

Good charting requires knowledge of the disease process, significant aspects of
the disease process which needs to be assessed and knowledge of the diagnostic
findings/medications. Also – charting requires common sense.

Everything on the flow sheet does not have to be repeated in the nurses notesonly if the information is pertinent to the client’s diagnosis/condition, indicates a
change or requires an explanation
Example: a client with pneumonia whose lungs are clear for the first time
since admission
A client just returned from OR for abdominal surgery whose abdomen is
soft

Fill flow sheets in completely with pertinent client information.

Chart only for yourself

Correct errors in documentation as soon as possible

Errors should be corrected by drawing a single line through them and the work
“error” written above them. Or use computer guidelines if computer charting.

Draw a line through any blank spaces.

If you document some aspect of the client’s care that is clearly out of
chronological order in the record, label it “late entry” and record the date and
time.

If your note is spread out on more than one page, mark each subsequent page as a
continuation of the original

Do not write critical or judgmental comments about the client, family or staff.

If you question an order or seek clarification regarding the client’s care, document
the action.
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
Use medical terminology only if you are sure of its meaning

Chart each medication, treatment, and procedure noting the time, effect, and
results

Chart the fact that the client has refused a medication or treatment, and state the
reason. Document any actions you took as well as whom you notified

Document incidents in the nurse’s notes in addition to doing so on the appropriate
incident form

DO NOT document in the nurse’s notes that you filled out an incident form.
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