Nursing Documentation and Recordkeeping
Documentation is the legal record of care and the nurse's best defense. Questions test whether you know what to write, when, and how. The standard is objective, timely, accurate, and complete documentation that reflects the nursing process.
Core concepts:
- Objectivity. Chart what you observe and measure ("dressing saturated with 4 cm of serosanguineous drainage"), not conclusions ("patient seems unhappy"). Quote the patient when relevant.
- Timeliness. Document at the time of care or as soon as possible; late entries are labeled as such with date and time.
- Accuracy and correction. Never erase or obliterate an error. Draw a single line, write "error," initial, date, and re-enter correctly, following facility policy for electronic records.
- Completeness. Record assessments, interventions, patient responses, teaching, and notification of providers. If it was not documented, it is treated as not done.
- Confidentiality. Follow HIPAA and facility rules for access and release of records; do not access records of patients not in your care.
- Do not chart in advance or document care provided by others as your own.
Traps: options that suggest altering a record to "fix" an error, charting opinions or blame, or documenting a provider's notification without the outcome. A common distractor is "document the incident in the patient's chart"-incident reports go to a separate risk-management system, while the chart gets only the factual clinical note.
Rule of thumb: If you would not want it read aloud in court, rewrite it in neutral, factual language.