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UCQ

Nursing Charting and Documentation

Avoiding Generalizations

The College of Registered Nurses of Manitoba Documentation Guidelines for Registered Nurses (2019, p.5) explains that:

Language used in charting and documentation should be precise, descriptive, and factual.

Factual language is what the nurse sees, feels, hears, and smells. 

Disruptive and agitated behaviour VS Client is yelling and pacing in hallway                                                                                                 Client appears in pain VS Client grimaces when moved from back-to-side
Client is non-compliant VS Client said he does not want to take his medication as it makes him feel nauseous
Client is a fall risk VS Client stumbles when walking and shuffles feet 
Client appears confused VS Client is disorientated to time and place
Client is depressed VS Client had a flat affect, limited eye contact and cried frequently during conversation
Wound is infected VS Skin around the wound is red, warm to touch with purulent discharge, client complains of 
increased pain over the past two days

Client has poor insight and is a safety risk VS Client found outside smoking with portal oxygen tank in use
Client appears to be hemorrhaging VS Client has saturated two peri-pads in one hour
Difficulties breathing VS Nasal flaring noted and lips blueish tinge

Avoid phrases like:

* Patient apparently slept well.

* Patient appears to have had a good day.

* Patient seems to feel ok.

Avoid words like:

* seems

* appears

* apparently.

Without facts and description, these words and phrases lack certainty.

Reference

College of Registered Nurses of Manitoba. (2019). Documentation guidelines for registered nurses.  https://crnm.mb.ca/uploads/ck/files/Documentation%20Guidelines%20for%20Nurses%20-%20web%20version.pdf