General Documentation Guidelines

1. Contents of a medical record must meet all regulatory, accrediting, and professional organization standards. Common requirements specific to nursing documentation include, but are not limited to: the nursing assessment and care provided; informed consent for any/all procedures; teaching provided either to the client directly or to his/her family; and response and reaction to teaching.
2. Use black permanent ink for entries.
3. Date, time, and sign all entries. Use first initial, last name and title. Full signature and title must be on file in agency.
4. Entries are to be legible with no blank spaces left on a line or in any area of the documentation. If a space is left on a line, draw a line through the space to the end of the line. For large areas not used on a form or page, use diagonal lines to mark through the area.
5. For errors, draw a line through the error, write error, initial and date the line. Do not attempt to erase, obliterate or “white out” the error.
6. Entries are to be factual, complete, accurate, contain observations, clinical signs and symptoms, client quotes when applicable, nursing interventions, and patient reactions. Do not give opinions, make assumptions, or enter vague, meaningless statements (e.g., “is a good parent”). Be specific.
7. Use correct grammar, spelling and punctuation.
8. Write client’s name and other identifying information on each medical record page.
9. Be sure to use only those abbreviations approved by your agency/facility.
10. Always record a client’s non-cooperative/non-compliant behavior.
11. Never document for someone else or sign another nurse’s name in any portion of the medical record.
12. Documentation should occur as soon after the care given as possible. Note problems as they occur, resolutions used and changes in client’s status.
13. When leaving messages, document time, name, and title of person taking message, and telephone number you called.
14. Record client assessment before and after you administer medications or other treatments.
15. Document any discussion of questionable medical orders, and the directions the doctor gave. Include the time and date of discussion and your actions as a result of the discussion and consequent directions given.
16. Chart an omission as a new entry. Do not backdate or add to previously written entries.
17. When an unusual incident occurs, document the incident on a special incident or occurrence report form. Do not write “incident report” filed in the medical record. Do write what happened to the client and actions taken to assure the client’s well-being in the medical record.
18. Record only your own observations, actions. If you receive information from another care giver, state the source of the information.
19. Record the date, time, and content of all telephone client-related communications.
20. REMEMBER, if you didn’t document it, it didn’t occur.

Reference
Brent, Nancy. (1997). Nurses and The Law. W. B. Saunders Company.

Kopf, Randi. Are Your Medical Records a Legal Asset or Liability? Legal Documentation Guidelines. Journal of Nursing Law. 1, (1).

Other Resources:
Missouri State Board of Nursing. (1996). Documentation/Charting Information Packet.

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