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UCQ

Nursing Charting and Documentation

Tips for Correct Nurses' Charting and Documentation

Correct and proper documentation should 

1. Be concise:
* Complete sentences are not necessary.
* Begin each entry with a capital letter and end with a full-stop.
2. Be permanent: 
* Ballpoint pen should be used. No felt or pencil should be used.
3. Be accurate:
* State facts regarding care.  Healthcare providers' opinions and interpretations should not be included.
* Use “ “ to show patients' statements.
* Include objective and factual data, such as temperature and BP.
* Note behaviours instead of the patient’s feelings.
4. Be appropriate:
* Include important and relevant data only.
5. Use only standard acronyms and terminology
6. Be signed
7. Be legible
8. Be confidential
9. Not leave spaces:
* Extra data should not be inserted in nurses' notes.
10. Be timely: 
* Information should be recorded immediately or as soon as possible afterwards.