Documentation/record-keeping
Documentation questions test precision and defensibility: whether the record would support your judgment if read a year later by a surveyor, a physician, or a court. The standard is objective, contemporaneous, complete, and attributable.
Rules
- Chart what you did, saw, heard, and taught - including the person's response and the follow-up.
- Be objective. "Client was agitated" is an interpretation. "Pacing, repeatedly striking the table with an open hand, and refusing lunch at 12:10; settled after 20 minutes with music" is data.
- Be specific. Percent of meal eaten, time, amount, color, size, and who was notified.
- Timeliness. Record as soon as practical after the event; if a late entry is unavoidable, label it as late, include the actual time, and do not backdate.
- Correct errors properly. Single line through the error, initial and date, and write the correct entry. Do not erase, use correction fluid, or overwrite.
- Document refusals - what was offered, what the person said or did, education given, and notification of the provider or guardian as appropriate.
- Confidentiality. Access only records needed for care; share only with those who need to know; know your agency's HIPAA and consent-to-release procedures.
- Incident reports document the event for risk management and generally are not filed in the clinical record; the clinical record still needs the objective facts and the person's condition.
Worked example
A staff member reports that a woman slipped in the bathroom but "seems fine." The nurse's note should record the time, mechanism as reported, the nurse's full assessment (neuro checks, pain assessment, skin inspection, vital signs), the person's own account, provider notification at a stated time and the response, instructions given to staff, and the plan for monitoring. "No injury noted, will monitor" alone would not survive review.
Traps
- Charting conclusions instead of observations.
- Vague terms: "appears," "seems," "a little," "as usual."
- Charting care before it was delivered, or backdating an entry.
- Recording another person's care on the wrong chart.
- Omitting the notification and the response.
- Putting opinions about a colleague's performance in the clinical record.