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Nursing Documentation Do's and Don'ts

General educational principles from nursing sources. Specific rules, such as charting frequency or correction steps, vary by organization.

Educational use & privacy

Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.

Nursing Notes Privacy & Safety

Do

  • Be objective, factual and professional. Open RN describes documentation as objective, factual and professional. Describe what you saw and heard rather than opinions.
  • Be accurate and relevant. ANA lists accurate, relevant, clear and concise among the characteristics of high-quality documentation.
  • Be timely and sequential. Document as soon as practical after care, in the order events happened (ANA).
  • Document what was assessed, observed or performed. Record assessments you actually completed and care you actually gave.
  • Distinguish patient statements from observations. Quote or attribute what the patient or family reports; label observations as your own findings.
  • Follow facility-approved terminology and abbreviations. Use your organization's approved list and avoid the Joint Commission Do Not Use items.
  • Use your organization's correction procedure. Open RN describes general principles for correcting errors in paper and electronic records. The specific steps depend on your organization's EHR and policy.

Don't

  • Don't chart care before it happens. Open RN states that care should not be charted before it is completed.
  • Don't document another person's care as your own. If someone else performed care, follow policy for how it is documented and attributed.
  • Don't make unsupported assumptions. Avoid conclusions such as "drug-seeking" or "noncompliant"; describe the facts.
  • Don't chart findings you did not assess. Never mark a system normal because it usually is.
  • Don't delete, hide or overwrite errors. Never conceal a documentation error or try to get around an audit trail. Correct it using your organization's policy.
  • Don't use the record for blame or complaints. Report concerns through the channels your organization provides.

ANA's six principles

ANA's Principles for Nursing Documentation groups guidance into six areas: documentation characteristics, education and training, policies and procedures, protection systems, documentation entries, and standardized terminologies.

See it in practice

Sources