MEDICAL CHARTING AND DOCUMENTATION
GENERAL GUIDELINES
When to Chart
1. Record nursing actions and individual responses as soon after they occur as possible.
2. Never document medications or treatments before they are given or completed. What to Chart
1. Symptoms: Use the person’s own words, communication gestures, or non-verbal cues as much as possible.
2. Your observations: Failure to document leaves gaps in the record that can be interpreted as neglect.
3. All injuries, illnesses and unusual health situations until they are resolved. There should
be entries in the nursing notes on a regular basis until the problem is no longer present. When the problem is resolved, it should be documented.
4. All contacts with the primary care prescriber:
a. Document what information was relayed to the primary care prescriber.
b. If the primary care prescriber sees or reviews an individual’s specific health
problem, document what occurred:
• the chart was reviewed,
• the individual was seen, or
• if the individual was examined.
c. If the contact is made by phone, document what was discussed and results of the contact (e.g., no orders given, observe).
d. Document the plan for follow-up (e.g., to see the physician on morning rounds).
5. Response to a medication or treatment: This includes therapeutic effects as well as side effects.
6. All appointments and consultations:
a. Name of consultant and specialty
b. Reason for consultation
c. Brief report of findings if available–if not, say so. If the consultation report is filed in the chart, the nursing note may refer the reader to the consultation report.
d. If the consultation report is filed in the chart and it includes follow-up plans, the nursing note may refer the reader to the consultation report.
e. The person’s response to appointment.
7. New symptoms or conditions: Each of the following should be documented in the nursing notes (or other designated documents) at the time of occurrence along with nursing action taken and the person’s response:
a. abrasions, cuts, pressure marks
b. falls and bumps, with or without apparent injury
c. elevated temperature
d. pressure ulcers including description and treatment until resolved
e. rectal checks for constipation including findings and treatment
f. seizures with complete description and treatment, if any
g. possible adverse reactions to food or medicine
h. refusal of meals or medications
i. vomiting including type, amount, and treatment
j. STAT medications including time order is received and time medication is given
k. unusual behavior or condition of the individual
l. diarrhea or any change in bowel pattern
m. any significant increase or decrease in weight
n. changes or unusual difficulty in obtaining vital signs
8. Routine, ongoing treatments or conditions: (e.g., acne)
Document status at least once quarterly and more frequently as indicated.
9. Any action you take in response to an individual’s problem.
10. As a general rule, do not chart actions completed by others. In some instances it is permissible to chart something done by someone else BUT your notation should identify the person who actually gave the care.
How to Chart
1. Date and time each entry.
2. Indicate both the time the entry is made into the record and the time the observation or activity took place.
3. All entries in the individual’s record should be written or printed legibly in permanent black ink.
4. Do not leave blank lines between entries. Draw a line through unused spaces before and after your signature.
5. Use only abbreviations and symbols approved in agency policies.
6. All entries in the individual’s record should be written objectively and without bias, personal opinion, or value judgment.
7. The use of slang, cliches, or labels should be avoided unless used in the context of a direct quote.
8. Interpretations of data should be supported by descriptions of specific observations.
9. Documentation should be clear, concise, and specific.
a. Don’t use vague terms.
b. Generalizations such as “good”, “fair”, “moderate”, and “normal” should be avoided.
c. Findings should be as descriptive as possible including specific information about the appearance or findings related to size, shape, and amount.
10. Correcting errors:
a. Draw one straight line through the incorrect entry,
b. Write “error” above it,
c. Initial and date the correction.
d. Never use white-out, erase, or obliterate an entry in the individual’s record.
11. Late entries: If you forget to chart something, it may be entered into the record at a later time but you must clearly state the date and time the entry is being made and the date and time the care or observations actually occurred. The entry should begin with the words “Late entry”.
12. All entries in the nursing notes should be signed. The signature should include the first initial, last name and title (e.g., S. Jones, RN, PCT, PhT or PHT).
13. A record of initials and signatures should be maintained according to facility policy so that the person using the initials and signatures used in documentation can be identified.
Title State facts;
Date
Time State interventions, within the scope of your practice;
State who was notified, ie supervisor, nurse, ect.
State outcome, how situation was solved within the scope of your practice
