Skip to Main Content
It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results.

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.