1. Verify Patient Information
The last thing you want to do is document in the wrong chart. You would think that this is obvious, but I have seen this occur one time too many in the field. Check the patient’s name and before you submit your documentations (especially online), double check the patient’s name.
2. Document as Soon as Possible
Of course everything happens so fast and you do not have time to document everything that happens as soon as it happens. In an ideal nursing world, this would happen. It would be amazing if you only had two patients to worry about and you can take your time. But soon as you get a chance, document away. Do not wait until the end of your shift to document everything. Errors have happened this way and the details won’t be as clear!
3. Remain Objective
The patient is being rude and mean. You cannot say this. You cannot say the patient is stubborn and refused his meal. You have to state what happened.
At 09:05 A.M., patient refused his meal due to lack of appetite. Offered again in 30 minutes and patient stated he rather wait until lunch to eat. Denies complaints of stomach ache, nausea, vomiting, constipation, or diarrhea. Pain is 0/10 at this time.
4. Ignore Trivial Information
You do not have to put down that the patient was watching television or playing cards with his buddies. You can state that the patient has no complaints at this time, is alert, and ambulatory. Denies pain 0/10 at this time.
5. Simple is Not a Bad Thing
You are not writing an essay and putting down as much information as possible. These notes are meant to be read by the interdisciplinary team that is taking care of him. Would you want to read an essay when you come to your nursing shift on every single one of your patient? Not really. It is designed to be simple and to the point.
6. Write Clearly
We are all in a rush. If you have to document manually and it is not done electronically, please do everyone a favor and write legibly. Miscommunication can easily happen due to someone’s handwriting being misinterpreted.
7. Use Standard Abbreviations
Do not make your own abbreviations or use the slang abbreviation such as lol and patient said ttyl. Use medical terminology that is universal for the interdisciplinary team to understand.
8. Do Not Chart in Advance
It is tempting to chart in advance, especially if you have a stable patient and you can predict his actions. However, you never know what will happen. You are not allowed to just rip the paper off or delete your electronic entry. You can only cross out with one line and electronic entries will be edited, but not deleted.
9. New Information Should Be Entered
If patient has new allergies or went to get a procedure done, this should be documented.
10. If Your Entry is Late
Document as early as possible and note the late entry. Do not just go the next day and pretend it never happened. In the nursing world, if it was not documented, then it did not happen!