The entries you make in the medical record should show you took appropriate actions in response to the patient’s condition. Record as close to the timing of the events as possible otherwise you may not remember key points, times, or persons that are important to record. Record “real-time” when documenting interventions. Real-time entries may avoid the appearance that a delay occurred in your response to significant findings. Always follow interventions with entries that show how the patient responded indicating the effectiveness of the intervention because not all interventions are effective as you know.
Referrals are often necessary for ongoing care and treatment. When referrals involve other providers, such as home care or social services, include interdisciplinary meetings discussions and patient current plan of care and discharge planning.
Essential Documentation Goals
- Accurately describe the patient’s condition and progress.
- Communicate clearly.
- Satisfy legal requirements.
Accurately describe the patient’s condition and progress
- List initial assessment data.
- Identify potential and actual problems on the plan of care.
- Describe specifically procedures, treatments, and medications administered.
- Describe the patient’s responses to procedures, treatments, and medications.
- Outline patient teaching by including topics covered and evaluation of the patients understanding using teach-back method or teach-to-goal.
- List nursing actions; interventions.
- Name individuals you consulted with regarding the patient’s condition.
- Record dates and exact times for assessments, interventions, and other events.
- State the facts in a concise manner.
- Use quotation when describing symptoms a patient tells you; avoid interpreting what they say.
- Describe only what you have seen, heard, touched, or smelled. “First-hand knowledge”.
- Avoid recording assumptions and personal opinions.
- Use only standardized abbreviations.
- Spell correctly. Check the spell check!
- All handwritten entries must be legible.
Satisfy legal requirements
- Make corrections according to your facility policy for documentation.
- Be accurate and truthful.
- Avoid omissions, blank spaces, or unused spaces.
- Follow your facility policy for documentation on forms.
- Record ALL communications with those who have the authority to give you orders.
- List all nursing assessment findings and actions taken.
- Never refer to an incident report or other documents that are not a part of the medical record.
- Sign your entries: handwritten or electronic as appropriate.