Nursing Documentation Best Practices

Documentation Do's

• Chart changes in a patient's condition and document actions taken to address the changes.
• Review nurses' notes before providing care to identify potential changes in a patient's condition.
• Document care in a timely manner. Late documentation is preferred to no documentation, although accuracy may be compromised with increased time between care and documentation.
• Use precise, objective, and factual descriptions in documentation.
• Correct any errors in documentation according to agency guidelines.
• Ensure correct spelling in all documentation.
• Record any teaching provided to patients.
• Document patients' exact words using quotation marks.

Documentation Don'ts

• Do not chart care in advance of providing it.
• Avoid the use of vague terminology in documentation.
• Do not chart for another person.
• Do not use "patient" instead of the patient's name in documentation.
• Do not alter the medical record, even when requested by a physician.
• Do not document assumptions or subjective opinions that might reflect bias. For example, avoid using terms like "complainer."

This quiz covers essential do's and don'ts of nursing documentation, focusing on how to accurately record a patient's condition and the actions taken. Learn the importance of timely, precise, and objective documentation, as well as common pitfalls to avoid. Enhance your awareness of best practices in nursing documentation.