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I am continually amazed when I go to patients chart to track a particular event, change in
condition etc.and I find less than adequate documentation. It is scary actually, because all
nurses have had it drilled into our heads that "if its not documented, it wasn't done!" The
most recent was just last week. Report was given that a patient had received 120mg I.V.
Lasix STAT the night before, but when I checked the chart for outcomes, I found that the
nurse did not even document the event at all!! Her reason: This was a long term care
resident, and didn't require daily charting!
Let's play the Devil's Advocate here.The patient in CHF does not clear.in fact he
worsens overnight, and eventually ends up with Pulmonary Edema and dies. The doctor reviews the chart, see's the telephone order for the Lasix and signs it, but no notation in the nurses note regarding the outcome! The family wants to know what happened. They ask
for the patients complete record. The case goes to court. As far as the family, prosecuting
attorney, judge, and jury are concerned. the Lasix was not given!! Who is at fault?
In this day and age, nurses have to be extremely vigilant in their assessments, and documentation. Here you will find a list of Do's and Don'ts. I will also be adding disease specific documentation guidelines in the very near future, so check back often. Feel free to print these out and use them at work!
? Check to be sure you have the correct chart before you begin writing. ? Make sure your documentation reflects the nursing process, and your professional
? Write Legibly ? On the M.A.R. be sure you document the Name of the medication (brand &
generic is most beneficial), Dose, Route, & Time; and in the case of p.r.n. or STAT medications be sure to document the medication name, dose, route, time, & response in the M.A.R. in addition to the nurses notes.
? Record each phone call to a physician, or nurse practitioner, including the exact
? Chart a patients refusal to allow treatment or take medication. Be sure to report
this to your manager, and patients physician.
? Chart all patient care at the time you provide it. ? If you remember an important point after you've completed your documentation,
chart the information at the time of remembrance, with the notation that it's a "late entry." Include the date and time of the late entry.
? Document enough to tell the WHOLE STORY.
? Don't chart a symptom such as 'c/o pain', without also charting what you did about
it, and the effects your actions had!!
? Don't alter a patient's record. This is a criminal offense!!
? Don't' use shorthand, or abbreviations that aren't widely accepted.
? Don't write imprecise descriptions such as "bed soaked", or a "large amount". ? Don't give excuses, such as "medication not given because not available" without
documenting how you went about obtaining the medication, and how you
monitored & cared for your patient in the absence of the medication. Always notify
the physician if & when a medication is not available because he/she may choose an
? Don't chart what someone else said, heard, felt, or smelled unless the information is
critical, and pertinent to your patients status. In that case, use quotations and attribute the remarks appropriately.
? Don't chart care ahead of time; something may happen and you may be unable to
actually give the care you've charted. Charting care that you haven't administered is
The NSO actually stated "Don't give excuses, such as "medication not given because not
available". However in the Long Term Care / Assisted Living Environments, healthcare
providers rely on daily deliveries from pharmacy. A STAT delivery can take up to 6 hours
at times. A recent example was of a resident that was exhibiting changes in mental status
including, delusions, combativeness, and aggression toward other residents secondary to a
urinary tract infection. The doctor ordered 0.5mg Haldol (Haloperidol) p.o. now, may
repeat x1 in 1 hour if no effect. The facility did not have Haldol on hand. However they
did have Ativan (Lorazepam). After realizing that the emergency kit did not contain
Haldol, the nurse called the doctor and he in turn ordered Ativan 1 mg p.o. now. Then
Ativan 0.5mg p.o. q4hours p.r.n. Agitation/Aggression x 2days. Re-evaluate patients mental
status in 2 days, and notify M.D. for follow-up.
Some information above was derived from the Nurse Service Organization's 1-day seminar
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a r z n e i - t e l e g r a m m 2007; Jg. 38 , Nr. 7 bensqualität von Patienten mit einer Erkrankung aus demcy for Healthcare Research and Quality, Evidence Report Nr. Waren-schizophrenen Formenkreis, bei denen ein Medikamenten-123, Mai 2005). Auch die aktuell publizierte MIND-IT*-Stu- zeichen inwechsel erforderlich ist, im folgenden Jahr unter einem vondie (VAN MELLE, J.P. et al.: Bri