Documentation

I. Key Aspect of Effective Documentation


LEGAL GUIDELINES FOR CHARTING

• Record the facts legibly, in ink
• Never erase, scratch out, or apply correction fluid. Cross through an error once, date and initial the change
• Do not leave blank spaces in your nursing notes
• Never chart for another person
• Avoid interpreting patient statement. Record exactly what the patient said in quotations marks
• Correct all errors in a timely manner
• Chart in a timely manner

COMPUTERIZED CHARTING

• Never lend access ID to another person
• Maintain confidentiality of documented information printed from the computer

II. Types of Documentation

• Problem-oriented medical record (POMR)
• Narrative documentation
• Focus charting
• Charting by exception

III. Documentation Guidelines

• General

1. Check that you have the correct chart
2. Altering a client chart is a criminal offense
3. Document enough information to describe the situation accurately

• Computerized

1. Use the user ID code, name or password
2. Do not tell anyone your password
3. Carefully check your information before you press enter
4. Log off when you are finished
5. Do not let clients observe other's information on the computer screen
6. Maintain privacy and confidentiality of documented information printed from the computer

• Paper-Ink

1. Use permanent ink of color according to agency policy
2. Use agency policies for error correction (usually one line drawn through the error, initial and date) and late entries
3. Do not document for others or change documentation for others
4. Include consent for or refusal of treatment, client responses to interventions, calls made to other health care professionals
5. Write legibly
6. Use only organization approved abbreviations
7. Chart the time and date for each entry