Good vs Poor Documentation Examples
Fictional side-by-side comparisons. The goal is accurate clinical communication, not defensive or legal tricks.
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 & SafetyVague vs specific
✗ Vague (fictional)
Ate well.
✓ Specific (fictional)
Ate 75% of dinner tray.
✗ Vague (fictional)
Some drainage on dressing.
✓ Specific (fictional)
3 cm area of serous drainage on dressing.
Why: Specific measures let the next reader compare.
Assumption vs observation
✗ Assumption (fictional)
Patient is confused because of the new medication.
✓ Observation (fictional)
Oriented to person only at 1400; oriented ×4 at 0800.
✗ Assumption (fictional)
Patient fell because he didn't call for help.
✓ Observation (fictional)
Patient found on floor beside bed; fall not witnessed.
Why: Record what you observed; causes you did not observe are assumptions.
Unsupported judgment vs objective description
✗ Judgment (fictional)
Patient is rude.
✓ Objective description (fictional)
Patient raised voice and said "get out of my room."
✗ Judgment (fictional)
Patient is lazy and won't walk.
✓ Objective description (fictional)
Patient declined to walk at 1000, stating "my legs hurt."
Why: Describing behavior and words is more useful and more professional than labels.
Missing response vs reassessment documented
✗ Missing response (fictional)
Cold pack applied to knee.
✓ Reassessment documented (fictional)
Cold pack applied to knee at 1300; at 1330 patient rates pain 3/10, down from 6/10.
✗ Missing response (fictional)
PRN antiemetic given.
✓ Reassessment documented (fictional)
Ondansetron 4 mg IV given at 0900 per PRN order; at 0930 patient rates nausea 1/10.
Why: Response closes the loop on every intervention.
Generic education statement vs specific education and response
✗ Generic (fictional)
Patient verbalized understanding.
✓ Specific (fictional)
Taught signs of low blood sugar using handout; patient named three signs from the handout.
✗ Generic (fictional)
Discharge teaching done.
✓ Specific (fictional)
Reviewed follow-up appointment and warning signs with patient and spouse; spouse asked about parking, question answered.
Why: Specific teach-back shows what was actually assessed.
Documenting before care vs documenting after care
✗ Before care (fictional)
(At 1300) "1400: Dressing changed, patient tolerated well."
✓ After care (fictional)
(At 1415) "1400: Dressing changed per order; patient rates pain 2/10 during change."
Why: Care should not be charted before it is completed. Documentation should reflect what actually happened.
Keep practicing
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College)
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax