Lesson 1, Topic 1
In Progress

Basic Guidelines for Documentation

May 1, 2021

The quality and accuracy of the nursing notes is extremely important. They have a decisive impact on the success or failure of communication: sometimes they clearly and concisely convey the intended message; and sometimes, in contrast, they cause confusion and errors in communication and patient care. Correct choice of words and spelling, grammar, and punctuation, in addition to good penmanship and other writing skills with non–computer-based systems, are critical. The LPN/LVN must ensure the information recorded in the chart is clear, concise, complete, and accurate.

The registered nurse (RN) has primary responsibility for each patient’s initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified. Contributions by all team members during this initial process and during later updating sessions are important.

The forms used to provide documentation of patient care vary based on each health care institution’s policy. Each facility uses a combination of graphics, care flow sheets, and narrative or SOAPE notes (see description in later material) to document observations, care, and responses. The LPN/LVN should be sure that nursing notes correlate with the medical orders, Kardex information, and nursing care plan.

Charting Rules

See Box 3-2 for generally accepted documentation rules that provide consistency in documentation between health care providers and facilities. These rules also meet the standards expected by the individuals and the agencies that use the charts. Some of the rules apply to handwritten documentation. With a computerized documentation system, as is used with an EHR or EMR, the LPN/LVN should follow the guidelines for that particular system.

Box 3-2 Basic Rules for Documentation

•All documents should have the correct patient name, identification number, date of birth, date, and time if appropriate.
•Use only approved abbreviations and medical terms.
•Be timely, specific, accurate, and complete.
•Write legibly (for written documentation).
•Follow rules of grammar and punctuation.
•Fill all spaces; leave no empty lines. Chart consecutively. Go line by line. Do not indent left margin.
•Chart after care is provided, not before.
•Chart as soon and as often as necessary.
•Chart only your own care, observations, and teaching; never chart for anyone else.
•Use direct quotes when appropriate.
•Be objective in charting: only what you hear, see, feel, smell.
•Describe each item as you see it: for example, “white metal ring with clear stone” (rather than “diamond ring”). Do not speculate, guess, or assume.
•Chart facts; avoid judgmental terms and placing blame.
•Document only what you observe, not opinions. Never use charting to accuse someone else.
•Sign each block of charting or entry as directed by the agency policy.
•When a patient leaves a unit (e.g., to go to x-ray, laboratory, or office), chart the time and the method of transportation on departure and return.
•Chart all ordered care as given or explain the deviation (nothing by mouth [NPO] for laboratory, off unit, refused, etc).
•Note patient response to treatments and response to analgesics or other special medications.
•Use only hard-pointed, permanent black ink pens; no erasures or correcting fluids are allowed on charts for written patient records.
•If a charting error is made, identify the error according to facility policy and make the correct entry.
•When making a late entry, note it as a late entry and then proceed with your notation: for example, “Late entry _______________,” or as dictated by the facility policy.
•Follow each institution’s policies and procedures for charting.
•Avoid use of generalized empty phrases such as “status unchanged” or “had good day.”
•If you question an order, record that clarification was sought. For example, do not record “physician made error,” but chart “Dr. Bradley was called to clarify order for __________.”