In black and white Documentation For Nurses

A written documentation, “nurse’s notes,” or “charting” provides above-board documentation & communication of information to further health care providers.

DOCUMENTATION Guiding Principle Do

[1] Be based on fact.

[2] Chart nursing actions (together with teaching) & output.

[3] Chart the whole thing that is clinically considerable.

[4] Note the position of injections to make available for patient safety (sufficient rotation of sites).

[5] At the end of each shift, check all charting for legibility and correctness.

[6] Accurate errors by drawing one line in the course of the incorrect data, then initialing.

[7] If you must chart out of series, write the recent date followed by “adding up to nurse’s notes of (date),” followed by the mislaid data.


DO NOT

[1] Do not chart opinions.

[2] Do not chart an exploit before it occurring (as well as medication administration).

[3] Do not erase or obliterate a record.

[4] Do not run off blank spaces.

[5] Do not chart medications specified by someone else. It is not probable to be sure about the uniqueness or amount of medication administered by any more.