what are the 5 legal requirements for nursing documentation

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Five Legal Requirements for Nursing Documentation

Five Legal Requirements for Nursing Documentation: Nursing documentation is an integral aspect of patient care, providing a comprehensive record of assessments, interventions, and outcomes. However, beyond its clinical significance, nursing documentation is subject to legal requirements that ensure accuracy, accountability, and patient confidentiality. Understanding these legal obligations is paramount for nurses to maintain compliance and safeguard both patient well-being and professional integrity.

Table of Contents

Introduction to Nursing Documentation

Nursing documentation includes recording all pertinent information related to patient care, including assessments, interventions, medications, and responses. It serves as a communication tool among healthcare providers, facilitates continuity of care, and supports clinical decision-making. Additionally, nursing documentation plays a crucial role in legal proceedings, serving as evidence of the care provided and the patient’s condition.

Importance of Nursing Documentation

Accurate and comprehensive nursing documentation is vital for several reasons. Firstly, it ensures continuity of care by providing a clear overview of the patient’s health status and treatment plan. Secondly, it facilitates effective communication among healthcare team members , reducing the risk of errors or omissions in care delivery. Moreover, nursing documentation serves as a legal document that can be referenced in litigation or regulatory investigations.

Legal Framework Surrounding Nursing Documentation

Hipaa compliance.

The Health Insurance Portability and Accountability Act (HIPAA) sets forth stringent guidelines for the protection of patients’ health information. Nurses must adhere to HIPAA regulations when documenting patient care to safeguard the confidentiality and privacy of sensitive medical data.

Standard of Care

Nurses are held to a professional standard of care, which requires them to provide services that meet established medical practices and protocols. Adequate nursing documentation is essential to demonstrate adherence to this standard and defend against allegations of negligence or malpractice.

Accuracy and Timeliness

Nursing documentation must be accurate, reflecting the patient’s condition, interventions performed, and outcomes achieved. Timeliness is also crucial, as delays in documentation can compromise the continuity of care and lead to errors in treatment.

Completeness

Documentation should be comprehensive, encompassing all relevant information regarding the patient’s care and response to interventions. This includes vital signs, medication administration, patient assessments, and any changes in condition.

Confidentiality

Maintaining patient confidentiality is paramount in nursing documentation. Nurses must ensure that sensitive information is not disclosed to unauthorized individuals and that all documentation is stored securely to prevent breaches of privacy.

Authentication

Each entry in the nursing documentation should be authenticated with the nurse’s signature or electronic identifier. This verifies the authenticity of the information provided and confirms the nurse’s accountability for the care delivered.

Communication

Nursing documentation serves as a means of communication both within the healthcare team and with external stakeholders, such as other providers or insurance companies. Clear, concise documentation facilitates effective communication and ensures everyone involved in the patient’s care is informed and coordinated.

Consequences of Inadequate Nursing Documentation

Inadequate nursing documentation can have serious repercussions, both for patient care and legal liability. Poor documentation may result in errors in treatment, delays in diagnosis, or adverse outcomes for patients. Moreover, incomplete or inaccurate documentation can weaken the nurse’s defense in legal proceedings and expose them to allegations of negligence or malpractice.

Best Practices for Meeting Legal Requirements

To ensure compliance with legal requirements for nursing documentation, nurses should adhere to best practices, including:

Regular Training and Education : Stay updated on HIPAA regulations and documentation standards through ongoing training and professional development.
Use of Electronic Health Records (EHR) : Utilize EHR systems to streamline documentation processes and enhance the accuracy and accessibility of patient records.
Collaboration with Interdisciplinary Team : Engage in open communication with other healthcare team members to ensure consistency and continuity of care documentation.
Documentation Review and Audit : Conduct regular reviews and audits of nursing documentation to identify areas for improvement and ensure compliance with legal standards.
Documentation Templates and Guidelines : Utilize standardized templates and guidelines for nursing documentation to promote consistency and completeness in record-keeping.

Nursing documentation is a clinical necessity and a legal obligation that carries significant implications for patient safety and professional liability. By adhering to legal requirements and best practices for documentation, nurses can ensure the integrity, accuracy, and confidentiality of patient records, thereby upholding the highest standards of care delivery.

Why is nursing documentation important?

Nursing documentation provides a comprehensive record of patient care, supports communication among healthcare providers, and serves as legal evidence of the care provided.

What are the consequences of inadequate nursing documentation?

Inadequate documentation can lead to errors in treatment, compromised patient safety, and legal liability for healthcare providers

How can nurses ensure compliance with legal requirements for documentation?

Nurses can ensure compliance by staying informed about HIPAA regulations, maintaining accuracy and timeliness in documentation, and utilizing standardized templates and guidelines.

Why is confidentiality important in nursing documentation?

Maintaining patient confidentiality protects sensitive medical information and ensures privacy rights are upheld, following HIPAA regulations.

Please note that this article is for informational purposes only and should not substitute professional medical advice.

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Nursing documentation plays a critical role in healthcare. Errors or incomplete information can affect data accuracy and ultimately best practices. Improper documentation also can contribute to adverse, sometimes fatal, patient outcomes. When you document completely and accurately, you reduce your liability risk and have the strongest legal defense in the event of a malpractice lawsuit or licensing board disciplinary action. You face many urgent demands during your shift and charting may seem like a distraction from the work of patient care, but nursing documentation provides essential information to other healthcare colleagues on the patient’s care team and fulfills the nursing professional requirement to maintain a complete care record.

Remembering everything that’s occurred during a shift and every element of care you’ve provided to patients is almost impossible, so your documentation serves as the only record detailing patients’ clinical status and their response to treatments and interventions. One of the most common mistakes made by novice nurses is documentation errors, which most likely result from their intense focus on perfecting clinical skills. Seasoned nurses, on the other hand, face heavy patient workloads and concentrate on completing care tasks during their shift, which may lead them to put this critical aspect of their professional role on the backburner and result in rushed, incomplete, or missing documentation.

Nurse documentation and the electronic health record

Protecting yourself from malpractice claims

Evolution of nursing documentation

When I began my nursing career in 1990, all nurses wrote shift assessments and nursing care tasks in a narrative note, which could take 45 to 60 minutes to complete at the end of my rounds. It was customary to write with black ink on day shifts, green on evenings, and red on nights. To ensure I had all three colors easily available depending on which shift I worked, I taped the pens together. We began using templates a few years later, which saved time by allowing nurses to simply check off assessment findings rather than writing a narrative note.

The adoption of the electronic health record (EHR) now allows nurses to document by clicking checklists on the computer screen with less narrative documentation required. However, although EHR’s provide clinical data for organizations to improve patient safety and evaluate the quality of care, nurses still carry the burden of completing documentation for a large assignment of patients. In 2022, according to Iuppa, inpatient nurses at the Cleveland Clinic spent approximately 123 minutes per shift navigating the EHR.

Document completely and accurately

For over 20 years, my job in quality improvement has involved reviewing patient charts in response to patient complaints or adverse events. Most of these records either lacked pertinent clinical data or vital information about the patient, which didn’t support that the nurse had provided appropriate care. For example, to highlight 10- to 15-minute monitoring of the patient during a shift, a nurse might document the following: “patient on the phone,” “patient off the phone,” and “patient eating dinner.” The nurse may have good intentions, but this doesn’t provide any information on the patient’s clinical status. (See Document clinically, objectively, thoroughly .)

what are the 5 legal requirements for nursing documentation

Incomplete documentation also presents a liability risk because it doesn’t provide an accurate description of the patient and may result in serious medical error. Consider this documentation: “Patient sitting on edge of the bed, nose bleeding and urinating on the floor.” Your first thought might be that the patient is experiencing some form of cognitive decline that jeopardizes their safety. This account doesn’t provide any relevant clinical details to explain the cause of the bleeding and urinating. A more informative and accurate documentation of the patient’s status might read as follows: “Patient is alert and oriented with a small amount of bloody drainage noted to the right side of the nose where the patient picked at an old scab. The patient is having difficulty using the urinal at the bedside with urine spilling onto the floor. A bedside commode was placed next to the bed and the patient was instructed to use it when urinating or to call the nurse for assistance. Patient verbalized understanding.” The revised documentation provides not only a precise description of the patient but also important clinical information about the nursing care provided. NurseJournal advises nurses to include the following information when documenting in the EHR:

Patient health status and drug information
Medications that have been given and discontinued
Nursing actions
Changes in the patient’s condition
Any orders given regarding the patient’s care

Poor documentation and career consequences

Failure to provide accurate and complete documentation puts you at risk of being named in a malpractice lawsuit, which might take years to resolve and may cause fear and a loss of confidence in your ability to practice as a nurse. I’ve been asked to provide a deposition for a lawsuit only once in my career. I wasn’t named as a defendant, but it was still a nerve-wracking experience. Being quizzed vigorously by the prosecuting attorney about a patient I took care of 5 years earlier isn’t something I want to go through again. If my documentation hadn’t supported the care I provided, the ordeal might have been much worse.

According to liability claim reports published by the insurance provider Coverys in 2021 and the Nurses Service Organization (NSO) in 2020, omissions or errors in nursing documentation were responsible for 72% of all EHR-related risk issues, and the second highest reason for liability claims against nurses. NSO’s analysis of the specific types of allegations related to nursing documentation revealed the following:

50% are due to fraudulent or falsified patient records
29% are due to failure to document treatment/care required by regulatory agencies
13% are due to documentation not accurately reflecting patient care
4% are due to inadequate or untimely documentation

Results from a Medscape survey of malpractice respondents found that 14% recognized that better documentation would have helped them avoid a malpractice claim. Many legal experts identify poor documentation (incomplete, inaccurate, or missing) as one of the most common nursing errors committed across the country and recommend that nurses make the effort to document each intervention they perform. In other words, “If it wasn’t written down, it never happened.”

In addition to legal liability, you also risk suspension or revocation of your license by your state’s board of nursing. The National Council for State Boards of Nursing, a nonprofit organization comprised of members from the boards of nursing in all 50 states, reports that cases of practice-related discipline commonly involve a breakdown or error in the nursing process, including failure to accurately document. NSO states: “While missing documentation can impede the ability to defend a nurse in a professional liability lawsuit, fraudulent or falsified documentation can also lead to a state board of nursing complaint.”

Investigations by a board of nursing vary by state, and depending on the severity of the allegation may require only a written statement from the nurse in response to the accusation or the board might decide to conduct a full investigation with witness interviews. This process can take several months. Once complete, the board will decide whether to close the case or file formal charges and present evidence at a hearing. Possible sanctions include fines, a reprimand or censure, probation, suspension, or revocation of your nursing license.

Statutes of limitation don’t apply to licensure revocation and disciplinary proceedings, so it might be several years before you’re notified of an allegation. Disciplinary actions are considered public information and are published in state and national databases, newsletters, websites, and Nursys, the national database for nurse licensure verification.

Address the challenges

Complete and accurate documentation provides a clear picture of a patient’s condition and how they’re responding to treatment, which then influences providers’ care decisions. Nurses face many time constraints and interruptions throughout their shifts that make documentation difficult, but this essential care step is just as important as your clinical proficiency. Nurses, educators, and organizations can take steps to address documentation challenges and ensure excellent quality of care. (See Documentation improvement: All hands on deck .)

American Nurse Journal. 2023; 18(8). Doi: 10.51256/ANJ082328

American Nurses Association. Principles for Nursing Documentation: Guidance for Registered Nurses. 2010. nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf

Gallegos A. Medscape malpractice report 2021. Medscape. November 19, 2021. medscape.com/slideshow/2021-malpractice-report-6014604#12

Iuppa N. Improving the electronic health record experience for nurses. Cleveland Clinic. consultqd.clevelandclinic.org/improving-the-electronic-health-record-experience-for-nurses

Leventhal R. Malpractice claims report: EHR documentation errors still far too common. Healthcare Innovation. November 4, 2020. hcinnovationgroup.com/clinical-it/electronic-health-record-electronic-medical-record-ehr-emr/news/21161325/malpractice-claims-report-ehr-documentation-errors-still-far-too-common

McKnight H, Moore SM. Nursing shared governance. Updated September 19, 2022. StatPearls. ncbi.nlm.nih.gov/books/NBK549862/

National Council for State Boards of Nursing. Discipline. ncsbn.org/discipline.htm

Nurses Service Organization and CNA. Nurse Professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. 2020. nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence

NurseJournal. The 5 most common mistakes made by new nurses. April 27, 2022. nursejournal.org/articles/most-common-mistakes-made-by-new-nurses

Nursing OnPoint. Nursing documentation. nursingonpoint.com/clinical-resources/documentation-laws-regulations/nursing-documentation/#2

Key words: nursing documentation, quality care, patient safety, nursing licensure

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Hankey L. Proper documentation protects patients and your license. American Nurse Journal. 2023;18(8):28-31. doi:10.51256/anj082328 https://www.myamericannurse.com/proper-documentation-protects-patients-and-your-license/

Documentation and Reporting in Nursing

Documentation systems in nursing serve as essential tools for recording patient information accurately and comprehensively. These systems vary from traditional handwritten charts to sophisticated electronic health record (EHR) platforms. How do these systems ensure patient privacy and confidentiality in an era of increasing digitalization? What are the key challenges faced by nurses in adapting to and utilizing electronic documentation systems effectively? How do documentation standards and regulations influence nursing practice and patient care outcomes?

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Quality client care relies heavily on efficient communication among healthcare professionals. Typically, health personnel engage in communication via discussions, reports, and records to ensure seamless coordination and collaboration. A discussion entails an informal verbal exchange among two or more healthcare personnel aimed at identifying or resolving a problem by establishing strategies. A report comprises oral, written, or computer-mediated communication designed to convey information to others. For example, nurses routinely provide updates on clients after a hospital shift.

A record , also referred to as a chart or client record , serves as a formal, legal document offering evidence of a client’s care, whether in written or computer-based format. Despite variations in documentation systems and forms across healthcare organizations, client records typically contain similar information. The act of recording information in a client record is known as charting , documenting , or recording , reflecting the standardized approach to documentation in healthcare settings.

Documentation is anything written or printed that is relied on as a record of proof for authorized persons. Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse .

Documenting and reporting in nursing serve multifaceted purposes crucial for effective healthcare delivery and accountability.

1. Communication. Through documentation and reporting, nurses facilitate seamless communication among healthcare professionals, ensuring the continuity of care and promoting patient safety .

2. Planning Client Care. Detailed documentation aids in the formulation and execution of individualized care plans, providing a comprehensive overview of patient needs, interventions, and outcomes.

3. Auditing Health Agencies. Accurate documentation enables health agencies to assess compliance with regulatory standards, identify areas for improvement, and ensure the provision of high-quality care.

4. Research. Documented data serves as valuable resources for research endeavors, contributing to evidence-based practice and advancements in nursing knowledge and patient care.

5. Education. Documentation and reporting provide valuable learning materials for nursing students and healthcare professionals, offering real-life case studies and examples to enhance understanding and skill development.

6. Reimbursement. Thorough documentation supports reimbursement processes by accurately reflecting the care provided to patients, ensuring proper billing and reimbursement for healthcare services.

7. Legal Documentation. Documentation serves as legal evidence of the care provided, protecting both patients and healthcare providers in case of litigation or disputes.

8. Health Care Analysis. Aggregated data from documentation and reporting systems allow for the analysis of healthcare trends, outcomes, and performance metrics, facilitating continuous quality improvement initiatives and informed decision-making.

Documentation System Methods

Effective documentation systems are integral to ensuring accurate communication, maintaining legal records, and supporting clinical decision-making .

1. Source–Oriented Medical Record

A source-oriented medical record (SOMR) is a traditional format for maintaining patient information, where each department or healthcare provider documents their observations, interventions, and outcomes in designated sections of the patient’s chart.

1. The Traditional Client Record

This method involves organizing patient information into a structured format where each healthcare provider or department has its section for documentation. This makes it straightforward for each team member to record and find information specific to their discipline.

2. Departmental Notations

Each person or department, such as nursing, physicians, or physical therapy, makes entries in separate sections of the client’s chart. This segregation allows each department to use forms and notation styles that best suit their needs, enhancing clarity and specificity in documentation.

3. Convenience and Traceability

The source-oriented approach is convenient because it enables healthcare providers from various disciplines to quickly locate and use the forms specific to their role. It also simplifies tracing information, as each type of data is consistently located in the same section, making it easier to follow the patient’s care journey over time.

4. Examples of Sectional Organization

For instance, the admissions department uses an admission sheet to record initial patient information, the physician uses an order sheet for prescribing treatments, a history sheet for recording the patient’s medical background, and progress notes to document ongoing patient care and outcomes. Each section is tailored to meet the documentation needs of different healthcare providers.

5. Narrative Charting

This traditional method of documentation involves recording patient information in a chronological narrative format within the source-oriented record. Narrative charting allows for detailed descriptions of patient conditions, care provided, and the patient’s response, offering a comprehensive and continuous account of the patient’s health status and care over time. This method is beneficial for capturing the nuances and context of patient care, although it can be time-consuming and less structured compared to modern electronic systems.

Advantages and Disadvantages of Source–Oriented Medical Record

After exploring various methods for structuring patient data, many healthcare organizations begin to consider the benefits and drawbacks of source-oriented charting. Nursing leaders, aiming to facilitate caregiving processes, recognize that addressing the challenges their teams encounter can lead to effective improvement strategies. Here are the key advantages and disadvantages of using source-oriented patient charting:

Advantages	Disadvantages
Seeing a Patient’s Progress According to Each Care Specialty	Difficulty Finding Up-to-date Information in Complex Cases
Visualizing Notes in the Order They Were Written	Fragmented Data Among Treating Providers
Tracking Progress Across the Multidisciplinary Team for Coordinated Discharge	Limited Cross-Referencing and Silo-Writing
Ease of Use for Individual Disciplines	Inconsistency in Documentation Styles
Detailed Documentation	Increased Risk of Errors
	Time-Consuming Data Compilation

The following are detailed advantages of using the Source-Oriented Medical Record System (SOMR):

1. Seeing a Patient’s Progress According to Each Care Specialty. With SOMR, healthcare providers can easily monitor the progress and specific interventions made by each discipline. This segmented approach allows specialists to focus on their areas of expertise without being overwhelmed by unrelated data.

2. Visualizing Notes in the Order They Were Written. This method organizes notes chronologically within each section, making it straightforward to locate the most recent updates and treatment plans. This can be particularly useful in rapidly changing clinical situations where up-to-date information is crucial.

3. Tracking Progress Across the Multidisciplinary Team for Coordinated Discharge. By maintaining clear, separate sections for each discipline, SOMR facilitates the tracking of patient progress across various specialties. This helps in coordinating a comprehensive discharge plan that considers all aspects of patient care, ensuring that all necessary treatments and follow-up actions are aligned.

4. Ease of Use for Individual Disciplines. Each healthcare provider can easily locate their specific section, reducing the time needed to find relevant forms and documentation. This can facilitate the process of recording and accessing information for each department.

5. Detailed Documentation. SOMR allows for detailed narrative charting, which can provide a comprehensive and nuanced account of patient care, capturing the context and specifics of patient interactions.

The following are the disadvantages of Source-Oriented Medical Record (SOMR):

1. Difficulty Finding Up-to-date Information in Complex Cases. When patients have multiple comorbidities and are seen by numerous specialists, it can be challenging to quickly find the most current information. The need to search through multiple sections can delay access to critical data.

2. Fragmented Data Among Treating Providers. SOMR often results in fragmented data, as information is siloed within each specialty’s section. This can make it time-consuming to compile a complete picture of the patient’s care, requiring cross-referencing between sections.

3. Limited Cross-Referencing and Silo-Writing. The isolated nature of documentation in SOMR can lead to limited cross-referencing between disciplines. This may result in duplicated information, where the same details are recorded multiple times, or missed information, where critical data is not communicated effectively across departments.

4. Inconsistency in Documentation Styles. Different departments might use varying styles and terminologies for documentation, which can cause confusion and inconsistencies when trying to integrate patient information from multiple sources.

5. Increased Risk of Errors. The separation of records can increase the risk of errors, such as conflicting information or omissions, as each provider might not have access to the full scope of the patient’s history and treatment plans.

6. Time-Consuming Data Compilation. Compiling a holistic view of the patient’s care requires significant time and effort to piece together information from various sections, potentially leading to delays in decision-making and care delivery.

2. Problem–Oriented Medical Record (POMR)

The Problem-Oriented Medical Record (POMR), established by Dr. Lawrence Weed in the 1960s, represents a significant shift in medical documentation by organizing patient data around specific problems rather than by the source of the information. This method is structured to enhance clarity, continuity, and comprehensiveness in patient care.

Establishment by Lawrence Weed. Dr. Lawrence Weed introduced POMR to address the limitations of traditional medical records. His goal was to create a more systematic and problem-focused approach that could improve clinical decision-making and patient outcomes .

Data Organization by Patient Problems. Unlike traditional source-oriented records, where information is compartmentalized by department (e.g., nursing notes , physician orders), POMR arranges all data based on the specific problems a patient is experiencing. This organization begins with a comprehensive problem list, which is the cornerstone of the POMR system. Each problem listed is then documented in a structured format, typically including:

The Four (4) Basic Components

1 . Database. A complete history and physical examination, along with initial lab results and diagnostic tests, provide a baseline of patient information.

2. Problem List. Derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved.

3. Plan of Care. For each identified problem, initial plans are developed and documented. These plans are divided into three categories: diagnostic (further tests needed), therapeutic (treatment plans), and patient education (information provided to the patient).

4. Progress Notes. Using the SOAP (Subjective, Objective, Assessment, Plan) format, progress notes detail ongoing care and updates for each problem. This format ensures consistency and thoroughness in documenting patient care.

Example: SOAP Format or SOAPIE and SOAPIER

The SOAP, SOAPIE, and SOAPIER formats provide structured and systematic approaches to documenting patient care. By following these formats, healthcare providers can ensure thorough and consistent documentation, facilitating effective communication, continuity of care, and informed decision-making. Each additional component (Intervention, Evaluation, and Revision) enhances the depth and adaptability of the documentation, allowing for a dynamic and responsive approach to patient management.

S – Subjective data
O – Objective data
A – Assessment
P – Plan
I – Intervention
E – Evaluation
R – Revision

The SOAP format is a structured method used for documenting patient care in the Problem-Oriented Medical Record (POMR) system. It provides a clear and systematic way to record clinical information, ensuring comprehensive and consistent documentation.

S – Subjective Data:

Description: This section includes information provided by the patient about their symptoms, feelings, and perceptions. It often includes the patient’s chief complaint , history of present illness, and any other relevant details expressed during the clinical encounter.
Example: “The patient reports experiencing sharp chest pain radiating to the left arm for the past two hours.”

O – Objective Data:

Description: This section contains observable and measurable facts obtained through physical examination, diagnostic tests, and laboratory results. Objective data are factual and can be verified by the healthcare provider.
Example: “ Blood pressure is 150/90 mmHg, heart rate is 95 bpm, and an ECG shows ST-segment elevation.”

A – Assessment:

Description: The assessment section provides the healthcare provider’s interpretation and analysis of the subjective and objective data. It includes a diagnosis or a list of potential diagnoses (differential diagnosis).
Example: “The patient is experiencing symptoms indicative of acute myocardial infarction ( heart attack ).”
Description: This section outlines the proposed plan of action to address the patient’s problems. It includes diagnostic tests, treatments, interventions, patient education, and follow-up plans.
Example: “Administer aspirin and nitroglycerin , perform a cardiac catheterization , and admit the patient to the ICU for monitoring and further treatment.”

The SOAPIE format extends the SOAP method by adding two additional components: Intervention and Evaluation.

I – Intervention:

Description: This section details the specific actions and treatments carried out to address the patient’s problems. It includes medications administered, procedures performed, and other therapeutic interventions.
Example: “Administered 325 mg of aspirin and 0.4 mg of nitroglycerin sublingually. Initiated intravenous access and started a heparin drip.”

E – Evaluation:

Description: The evaluation section documents the patient’s response to the interventions. It assesses the effectiveness of the treatments and any changes in the patient’s condition.
Example: “The patient’s chest pain decreased from 8/10 to 3/10, and repeat ECG shows reduced ST-segment elevation.”

The SOAPIER format further expands SOAPIE by including a Revision component, ensuring a comprehensive approach to patient care documentation.

R – Revision:

Description: This section involves revisiting and updating the care plan based on the patient’s response and evaluation results. It may involve modifying treatment plans, adding new interventions, or setting new goals.
Example: “Revised the care plan to include a cardiology consult and additional diagnostics such as a stress test. Adjusted medication dosages based on the patient’s response.”

Advantages and Disadvantages of Problem–Oriented Medical Record (POMR)

Like any system, POMR has strengths and weaknesses that can impact its effectiveness in different healthcare settings. The advantages and disadvantages of utilizing problem-oriented medical records include the following:

Advantages	Disadvantages
Encourages Collaboration	Varied Ability to Use the Charting Format
Problem List at the Front	Constant Vigilance Required
Improved Patient Care	Inefficiency Due to Repetition
Clear and Structured Documentation	Time-Consuming
Enhanced Communication	Learning Curve

The advantages of the Problem-Oriented Medical Record (POMR) include:

1. Encourages Collaboration. POMR promotes teamwork among healthcare providers by ensuring that all members of the care team are aware of the patient’s problems and the planned interventions. This fosters a more integrated and coordinated approach to patient care.

2. Problem List at the Front. Having a problem list at the front of the chart immediately alerts caregivers to the patient’s current and past issues. This centralized list makes it easier to track the status of each problem, ensuring that no issues are overlooked and that all team members can quickly grasp the patient’s overall condition.

3. Improved Patient Care. By systematically addressing each problem, POMR ensures comprehensive patient assessments and targeted interventions, potentially leading to better health outcomes.

4. Clear and Structured Documentation. The standardized format of POMR, including the use of SOAP (Subjective, Objective, Assessment, Plan) notes, helps maintain consistency in documentation, making it easier to follow the patient’s care journey.

5. Enhanced Communication. The clear organization and detailed documentation facilitate better communication among multidisciplinary teams, reducing misunderstandings and improving the continuity of care.

The disadvantages of the Problem-Oriented Medical Record (POMR) include:

1. Varied Ability to Use the Charting Format. Not all caregivers have the same level of proficiency in using the POMR system. Differences in training and familiarity with the required charting format can lead to inconsistencies and errors in documentation.

2. Constant Vigilance Required. Maintaining an up-to-date problem list requires continuous attention and effort. If the list is not regularly updated, it can quickly become inaccurate, compromising the effectiveness of the POMR system.

3. Inefficiency Due to Repetition. Since assessments and interventions often apply to more than one problem, information may need to be repeated in multiple sections. This can be somewhat inefficient and time-consuming, increasing the administrative burden on healthcare providers.

4. Time-Consuming. The detailed nature of POMR documentation can be time-consuming, which may be challenging in fast-paced clinical environments. This can potentially detract from the time available for direct patient care.

5. Learning Curve. Implementing POMR requires training and adaptation for healthcare providers who are accustomed to traditional documentation methods. This initial learning curve can slow down the adoption process and temporarily impact efficiency.

3. PIE (Problems, Interventions, and Evaluation)

The PIE documentation system is an efficient approach to organizing patient information, focusing on Problems, Interventions, and Evaluation. This method aims to simplify and integrate care documentation into a continuous, real-time process.

The PIE documentation model groups information into three categories:

Problems (P). Identifies and lists the patient’s health issues or nursing diagnoses .
Interventions (I). Records the specific actions taken to address the identified problems.
Evaluation (E). Documents the patient’s response to the interventions and the effectiveness of the care provided.

The following are the key components of the PIE (Problem, Intervention, Evaluation) System:

1. Client Care Assessment Flow Sheet

The flow sheet is a crucial part of the PIE system, providing a structured and organized way to record patient assessments. It includes specific assessment criteria that are often categorized based on human needs or functional health patterns.
Example: A flow sheet might include sections for vital signs, pain levels, mobility status, and other key indicators of the patient’s health.

2. Progress Notes

Progress notes in the PIE system are used to document ongoing patient care in a narrative form. These notes are directly linked to the problems identified, the interventions carried out, and the evaluations of those interventions.
Example: A progress note might detail a nurse’s observation of a patient’s response to a new medication , including any side effects or improvements in symptoms.

Flow sheets are designed with particular assessment criteria to ensure consistency and comprehensiveness. They might be formatted according to frameworks such as Maslow’s hierarchy of needs or Gordon’s functional health patterns. Examples of specific criteria could include sections for physical health (e.g., cardiovascular, respiratory), psychosocial status, and functional abilities (e.g., activities of daily living ).

The PIE system eliminates traditional care plan and integrates into progress notes. The PIE system does away with separate, traditional care plans. Instead, the ongoing care plan is integrated directly into the progress notes, making the documentation process more dynamic and less fragmented. By incorporating the care plan into the progress notes, the PIE system ensures that the care plan is continuously updated and reflective of the patient’s current status and needs.

Advantages and Disadvantages of the PIE System

The following are the advantages and disadvantages of the PIE System:

Advantages	Disadvantages
Efficient Documentation	Potential for Oversight
Enhanced Continuity of Care	Learning Curve
Focused and Relevant Information	Detail Management

The advantages of the PIE System include:

1. Efficient Documentation. By combining the care plan and progress notes, the PIE system simplifies the documentation process, reducing redundancy and saving time.

2. Enhanced Continuity of Care. Continuous updates within the progress notes ensure that all care team members are informed of the latest patient status and interventions, promoting better continuity of care.

3. Focused and Relevant Information. The focus on problems, interventions, and evaluations ensures that the documentation remains relevant and directly related to patient care, improving clarity and utility.

The disadvantages of the PIE System include:

1. Potential for Oversight. With the elimination of a separate care plan, there might be a risk of missing long-term goals or broader care strategies that are not immediately linked to specific problems.

2. Learning Curve. Transitioning to the PIE system requires training and adjustment, particularly for staff used to traditional documentation methods.

3. Detail Management. The integrated nature of the system means that maintaining detailed and comprehensive records requires diligence to ensure that no critical information is overlooked or inadequately documented.

4. Focus Charting

Focus Charting is a documentation method designed to prioritize the patient’s concerns, needs, and strengths in the healthcare record. This system helps ensure that patient-centered care is maintained, providing a clear, organized approach to documenting care activities and patient responses.

See also: Focus Charting (F-DAR): How to do Focus Charting or F-DAR

The following are components of focus charting :

1. Client-Centered Focus

Focus Charting is intended to keep the patient and their concerns at the forefront of the documentation process. This method highlights the patient’s issues, strengths, and achievements, ensuring that care is tailored to their specific needs and circumstances.
Instead of documenting solely on clinical tasks or assessments, a nurse might focus on a patient’s progress in managing pain , their concerns about upcoming surgery , or their efforts in physical therapy.

2. Three Columns for Recording

Date and Time. This column logs when the care was provided, offering a chronological view of the patient’s progress and the timing of interventions.
Focus. The focus column specifies the main issue, concern, or strength being addressed. This could include a specific condition, symptom, behavior, or patient goal. Examples: “Pain management,” “Nutritional status,” and “Patient anxiety about discharge”
Progress Notes. The progress notes detail the actions taken and the patient’s responses, organized into three categories known as DAR.

3. DAR Format

D – Data. This section includes subjective and objective information relevant to the focus. It captures the initial assessment and observations that identify the patient’s current status. Example: “Patient reports pain level of 7/10 in the lower back, grimacing when moving .”
A – Action. This section documents the interventions performed in response to the data. It includes treatments, procedures, patient education, and any other actions taken by the healthcare provider. Example: “Administered prescribed analgesic and assisted patient with repositioning. Educated patient on proper lifting techniques to avoid strain.”
R – Response. This section records the patient’s reactions and outcomes following the interventions. It evaluates the effectiveness of the actions taken and notes any changes in the patient’s condition. Example: “Patient’s pain level decreased to 3/10 within 30 minutes post- medication . Patient verbalized understanding of lifting techniques.”

Advantages and Disadvantages of Focus Charting

The following are the advantages and disadvantages of focus charting :

Advantages	Disadvantages
Patient-Centered Care	Training Requirements
Clarity and Organization	Time-Consuming
Enhanced Communication	Risk of Incomplete Documentation
Comprehensive Documentation

Here are the advantages of Focus Charting:

1. Patient-Centered Care. By focusing on the patient’s concerns and strengths, this method ensures that care is tailored to individual needs, promoting holistic and personalized care.

2. Clarity and Organization. The structured format of Focus Charting provides clear and organized documentation, making it easier for healthcare providers to quickly understand the patient’s status and the care provided.

3. Enhanced Communication. The use of the DAR format helps ensure that critical information is communicated effectively among healthcare team members, facilitating better coordination and continuity of care.

4. Comprehensive Documentation. The inclusion of data, actions, and responses ensures that all aspects of patient care are documented comprehensively, supporting better clinical decision-making and care planning .

Here are the disadvantages of Focus Charting:

1. Training Requirements. Implementing Focus Charting requires training for healthcare providers, particularly those accustomed to other documentation methods. This can initially slow down documentation processes.

2. Time-Consuming. Ensuring thorough and detailed entries in the DAR format can be time-consuming, potentially increasing the administrative burden on healthcare providers.

3. Risk of Incomplete Documentation. If not consistently followed, there is a risk of incomplete documentation, particularly if the focus is not updated to reflect new patient concerns or if the response section is neglected.

5. Charting by Exception

Charting by Exception (CBE) is a documentation system that focuses on recording only abnormal or significant findings, or exceptions to established norms. This method aims to facilitate documentation, reduce redundancy, and highlight critical information, making it easier for healthcare providers to quickly identify and address issues that deviate from expected outcomes.

The following are the key components of Charting by Exception:

1. Flow Sheets

Flow sheets are used to document routine care and normal findings in a standardized, concise format. These sheets include predefined parameters and checklists for various aspects of patient care, such as vital signs, intake and output , and other routine assessments.
Example: A flow sheet for vital signs might have columns for recording temperature, blood pressure , heart rate , and respiratory rate at regular intervals, with spaces to note any deviations from the norm.

2. Standards of Nursing Care

Standards of nursing care provide the baseline or normal criteria for patient assessments and interventions. These standards are based on established best practices and clinical guidelines, serving as reference points for what is considered normal or expected.
Example: For a postoperative patient, the standards might include expected ranges for vital signs, typical recovery milestones, and standard pain management protocols. Deviations from these standards would be documented as exceptions.

3. Bedside Access to Chart Forms

Bedside access to chart forms ensures that documentation tools are readily available where care is provided. This facilitates immediate recording of exceptions and ensures that critical information is captured in real-time.
Example: Electronic health records (EHR) systems with mobile tablets or bedside computers allow nurses to quickly document exceptions during patient rounds, reducing delays and improving accuracy.

Advantages and Disadvantages of Charting by Exception

While CBE offers several advantages, such as increased efficiency and clarity in medical records, it also comes with potential disadvantages, including the risk of missing important details and the need for thorough initial assessments and training. What are the specific benefits and challenges of implementing CBE in clinical practice ? The following are the advantages and disadvantages of charting by exception:

Advantages	Disadvantages
Efficiency	Risk of Missing Details
Clarity	Dependence on Accurate Baselines
Reduced Redundancy	Training Requirements
Enhanced Focus on Patient Needs	Potential for Complacency

The following are the notable advantages of Charting by Exception (CBE):

1. Efficiency. By focusing only on abnormal or significant findings, CBE reduces the time spent on documentation, allowing healthcare providers to allocate more time to direct patient care.

2. Clarity. CBE highlights deviations from the norm, making it easier for care teams to identify and address issues that require attention. This can improve the detection of patient problems and prompt timely interventions.

3. Reduced Redundancy. CBE minimizes repetitive documentation of routine care, reducing the risk of documentation fatigue and errors. This approach ensures that records are concise and focused on relevant information.

4. Enhanced Focus on Patient Needs. By concentrating on exceptions, CBE helps healthcare providers prioritize significant changes in the patient’s condition, facilitating more targeted and effective care.

The following are the disadvantages of Charting by Exception (CBE):

1. Risk of Missing Details. If not properly implemented, there is a risk that important but seemingly routine information might be overlooked or not documented, potentially missing subtle signs of patient deterioration.

2. Dependence on Accurate Baselines. Effective CBE relies on well-defined standards of care and accurate initial assessments. Inaccurate baselines can lead to misinterpretation of what constitutes an exception, compromising patient safety.

3. Training Requirements. Staff must be adequately trained to recognize and document exceptions accurately. Inadequate training can result in inconsistent documentation practices and reduced effectiveness of the CBE system.

4. Potential for Complacency. There is a risk that staff might become complacent, assuming that no documentation implies no issues, which could lead to underreporting of important patient information.

The following comprehensive list outlines the various implementation considerations to be mindful of when adopting Charting by Exception (CBE) as a documentation method within a healthcare setting:

1. Develop Comprehensive Standards of Care. Clearly defined standards are essential for effective CBE. These should be based on evidence-based practices and regularly updated to reflect current guidelines.

2. Ensure Thorough Initial Assessments. Accurate and detailed initial patient assessments establish the baseline for what is considered normal, making it easier to identify exceptions.

3. Provide Adequate Training. Training programs should focus on helping staff recognize significant findings and understand the importance of documenting exceptions accurately.

4. Utilize Technology. Implementing electronic health records (EHR) with decision support tools can aid in identifying exceptions and facilitate the documentation process.

6. Computerized Documentation

Computerized documentation systems have been developed to manage the vast amount of information required in modern healthcare. These systems leverage technology to facilitate the documentation process, enhance accuracy, and improve access to patient information. Here’s a closer look at how computerized documentation functions and its benefits:

1. Managing Large Volumes of Information

Contemporary healthcare generates extensive amounts of data, including patient histories, diagnostic results, treatment plans, and progress notes. Computerized documentation systems are designed to handle this information efficiently, allowing for secure storage, quick retrieval, and comprehensive management.
Example: A patient’s entire medical history , from initial consultation to discharge summaries, can be stored in an electronic health record (EHR) system, accessible with a few clicks.

2. Functions for Nurses

Storing Client Databases . Nurses can input and store detailed patient information in a centralized database, including demographics, medical history, allergies, medications, and more. Example: Upon admission, a nurse enters a patient’s personal information, medical history, and initial assessment into the system.
Adding New Data. As patient care progresses, new information can be continuously added. This includes updates from ongoing assessments, lab results, and observations. Example: During each shift, nurses update the patient’s vital signs, symptoms, and any changes in condition.
Creating and Revising Care Plans. Nurses can develop, modify, and update care plans based on real-time patient data. These care plans can be customized to meet individual patient needs. Example: A care plan for a diabetic patient might include regular blood sugar monitoring, dietary adjustments, and medication administration , all updated as the patient’s condition evolves.
Documenting Client Progress. All aspects of patient care and progress are documented in the system. This includes interventions performed, patient responses, and outcomes. Example: If a patient receives a new medication, the nurse documents the administration and monitors the patient’s reaction, noting any side effects or improvements.

3. Elimination of Multiple Flow Sheets

In traditional documentation, multiple flow sheets are used to record different types of data (e.g., vital signs, medication administration, nursing assessments). In computerized systems, this information is integrated and can be easily retrieved in various formats.
Advantages. This integration reduces redundancy, minimizes the risk of errors, and ensures that all relevant data are available in a cohesive manner. Example: Instead of consulting separate charts for a patient’s vital signs, lab results, and medication history, a nurse can view all this information on a single digital interface.

Advantages and Disadvantages of Computerized Documentation

By replacing traditional paper-based methods with digital systems, healthcare providers can ensure more accurate, consistent, and accessible records. However, the adoption of computerized documentation comes with its own set of challenges.

Advantages	Diadvantages
Efficiency	Cost and Implementation
Accuracy and Consistency	Technical Issues
Accessibility	Data Entry Burden
Enhanced Communication	Learning Curve
Data Security and Privacy

The following outlines the various advantages and benefits associated with the integration and utilization of computerized documentation systems within healthcare settings:

1. Efficiency. Computerized systems streamline the documentation process, reducing the time needed for data entry and retrieval. This allows healthcare providers to focus more on direct patient care.

2. Accuracy and Consistency. Digital records minimize errors associated with manual documentation, such as illegible handwriting or misplaced charts. Standardized formats ensure consistency across the board.

3. Accessibility. Patient information can be accessed quickly from multiple locations, facilitating better coordination and continuity of care. This is especially beneficial in emergency situations or when consulting with specialists.

4. Enhanced Communication. Electronic health records improve communication among healthcare team members, as updates are made in real-time and are immediately available to all authorized personnel.

5. Data Security and Privacy. Modern computerized systems include robust security measures to protect patient data, ensuring compliance with regulations like HIPAA (Health Insurance Portability and Accountability Act).

Here are some of the disadvantages of computerized documentation:

1. Cost and Implementation. Initial setup costs for electronic systems can be high, and implementation requires significant time and resources. Training staff to use these systems effectively is also necessary.

2. Technical Issues. System downtimes, software glitches, and other technical issues can disrupt the documentation process and access to critical information.

3. Data Entry Burden. While digital systems aim to reduce redundancy, the need for thorough data entry can still be time-consuming and may contribute to clinician burnout if not managed properly.

4. Learning Curve. Healthcare providers need to be adequately trained to use computerized systems efficiently. A lack of proficiency can lead to errors or incomplete documentation.

7. Case Management

Case management is a coordinated approach to delivering high-quality, cost-effective healthcare within an established timeframe. This method focuses on optimizing patient outcomes and resource utilization, ensuring that care is both efficient and effective.

1. Emphasis on Quality and Cost-Effective Care

Case management prioritizes the delivery of high-quality care that meets established standards while also being mindful of cost constraints. This approach ensures that patients receive the necessary care without unnecessary delays or expenses.
Example: A case manager might coordinate care for a patient with chronic heart disease, ensuring they receive timely interventions, appropriate follow-up, and education on lifestyle changes to prevent readmissions, all while managing costs.

2. Established Length of Stay

Care plans are designed to achieve specific health outcomes within a predetermined length of stay in the healthcare facility. This helps in controlling healthcare costs and improving bed availability for other patients.
Example: For a patient undergoing knee replacement surgery , the case management plan would outline a typical hospital stay duration, including preoperative assessments, surgery , postoperative care, and rehabilitation, aiming to discharge the patient within a set timeframe.

3. Multidisciplinary Approach

Case management involves a team of healthcare professionals from various disciplines working collaboratively to plan and document patient care. This ensures comprehensive care that addresses all aspects of the patient’s health needs.
Example: The care team for a stroke patient might include doctors, nurses, physical therapists, occupational therapists, social workers, and dietitians, all contributing to a unified care plan.

4. Use of Critical Pathways

Critical pathways are standardized, evidence-based plans that outline the essential steps in the care process for specific clinical conditions or procedures. These pathways guide the multidisciplinary team in delivering consistent and efficient care.
Example: A critical pathway for managing a patient with pneumonia would include guidelines for diagnosis, antibiotic administration, patient monitoring, respiratory therapy, and discharge planning.

5. Managing Variances

In case management, a variance refers to any deviation from the expected outcomes or established critical pathway. Identifying and addressing variances is crucial for maintaining the quality and effectiveness of care.
Example: If a patient with pneumonia does not show expected improvement within the timeline set by the critical pathway, this would be noted as a variance. The care team would then investigate the cause (e.g., antibiotic resistance, comorbid conditions) and adjust the care plan accordingly.

Like any healthcare approach, case management is not without its challenges and limitations. While it offers numerous benefits, such as improved patient outcomes and enhanced efficiency, it also presents certain drawbacks, including implementation complexities, privacy concerns, and technological barriers.

Advantages	Disadvatages
Patient Care	Initial Implementation Challenges
Efficiency and Coordination	Technical Issues and Integration Challenges
Resource Optimization	Privacy and Security Concerns
Data-driven Insights	User Interface Complexity
Compliance and Documentation Accuracy	Risk of Data Overload

The advantages of case management are multifaceted, encompassing improvements in patient outcomes, enhanced coordination among healthcare providers, and greater efficiency in resource utilization. The following are the advantages of case management approach in detail:

1. Holistic Patient Care. Case management documentation systems enable a comprehensive overview of a patient’s care journey, consolidating medical, social, and support services information into a single platform. This holistic approach promotes continuity of care and facilitates better-informed decision-making by healthcare professionals.

2. Efficiency and Coordination. By centralizing patient information, case management systems streamline communication and coordination among multidisciplinary healthcare teams. This can lead to improved efficiency in care delivery, reduced duplication of efforts, and smoother transitions between different care settings.

3. Resource Optimization. With enhanced visibility into patient needs and progress, case management documentation systems help optimize resource allocation. This includes better utilization of staff time, appropriate allocation of medical supplies and equipment, and optimization of financial resources by identifying cost-effective interventions.

4. Data-driven Insights. These systems often include reporting and analytics functionalities, allowing healthcare organizations to derive valuable insights from aggregated data. By analyzing trends, outcomes, and resource utilization patterns, organizations can identify areas for improvement, implement evidence-based practices, and enhance overall quality of care.

5. Compliance and Documentation Accuracy. Case management documentation systems facilitate compliance with regulatory requirements and accreditation standards by ensuring thorough and accurate documentation of patient assessments, interventions, and outcomes. This documentation not only supports legal and regulatory compliance but also strengthens the defense against potential litigation.

Here are some of the disadvantages of the case management approach in the documentation system:

1. Initial Implementation Challenges. Implementing a case management documentation system can be resource-intensive and disruptive to established workflows. Healthcare organizations may encounter resistance from staff members who are accustomed to traditional documentation methods, requiring comprehensive training and change management strategies to facilitate adoption.

2. Technical Issues and Integration Challenges. Technical problems such as system downtime, software glitches, and data interoperability issues can impede the smooth functioning of case management documentation systems. Integration with existing electronic health record (EHR) systems and other healthcare IT infrastructure components may also present challenges, potentially leading to data silos and inefficiencies.

3. Privacy and Security Concerns. Storing sensitive patient information in electronic format raises concerns about data privacy and security. Healthcare organizations must implement robust cybersecurity measures to protect against unauthorized access, data breaches, and other security threats. Compliance with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) is essential but requires ongoing vigilance and investment in cybersecurity resources.

4. User Interface Complexity. Complex user interfaces and cumbersome data entry processes can frustrate healthcare professionals and hinder productivity. Poorly designed systems may lead to documentation errors, incomplete records, and user dissatisfaction, undermining the intended benefits of case management documentation.

5. Risk of Data Overload. While case management documentation systems aim to provide comprehensive patient information, there is a risk of information overload. Clinicians may struggle to identify relevant data amidst a sea of extraneous information, potentially leading to cognitive overload, decision fatigue , and suboptimal clinical decision-making.

Documenting Nursing Activities

The client record must detail the client’s current condition and encompass the entirety of the nursing process . Regardless of the record-keeping system used by an agency, nurses document the nursing process through various forms within the clinical record.

Nursing Care Plan (NCP)

A nursing care plan (NCP) is a critical tool in healthcare that outlines the individualized care to be provided to a client. It serves as a roadmap for the nursing team, ensuring that all aspects of the client’s health are addressed in a systematic and organized manner. There are two primary types of Nursing Care Plans : Traditional Care Plans and Standardized Care Plans.

For the full guide, please see: Nursing Care Plan (NCP) Ultimate Guide

A Traditional Care Plan is tailored specifically for each client. It is detailed and personalized, addressing the unique needs of the individual. This type of care plan typically consists of three columns:

Nursing Diagnoses. This column identifies the specific health problems or needs of the client. Each diagnosis is based on a thorough assessment and provides a foundation for the rest of the care plan.
Expected Outcomes. Here, the desired results or goals of the nursing interventions are listed. These outcomes are specific, measurable, and time-bound, ensuring that they are achievable within a certain period. They provide a clear direction for nursing care and a way to evaluate progress.
Nursing Interventions. This section outlines the actions that the nursing team will take to address the client’s needs and achieve the expected outcomes. Each intervention is evidence-based and tailored to the client’s specific situation, ensuring personalized and effective care.

A Standardized Care Plan, on the other hand, is developed based on an institution’s established standards of practice. These care plans are designed to ensure a high quality of care across the board, promoting consistency and efficiency within the healthcare facility. They are not individualized for each client but provide a general framework that can be adapted as needed. Key features include:

Institutional Standards. The care plans reflect the best practices and protocols established by the healthcare institution. These standards are based on current evidence and guidelines in the nursing profession, ensuring that all clients receive care that meets a high level of quality.
Consistency in Care. By using a standardized approach, nurses can provide consistent care to all clients, which is especially useful in larger healthcare settings where many nurses might be involved in a client’s care. This consistency helps in maintaining a uniform standard of care and reduces variability.
Efficiency. Standardized care plans save time for the nursing staff, as they do not need to create a new plan from scratch for each client. Instead, they can use the pre-established plan as a base and modify it to fit the specific needs of the client, ensuring both thoroughness and efficiency.

A KARDEX is a widely used, concise method of organizing and recording data about a client, making essential information quickly accessible to all health professionals involved in the client’s care. The KARDEX system helps streamline communication and ensure continuity of care. Here’s an in-depth look at the KARDEX system:

The following are the features of the KARDEX system:

1. Concise and Comprehensive

The KARDEX provides a summary of important information about the client, including medical history, current diagnosis, treatments, medications, and nursing care plans . This concise format ensures that health professionals can quickly understand the client’s status and needs.

2. Accessible

The KARDEX system is designed to be easily accessible to all members of the healthcare team. Whether kept in a portable index file or on computer-generated forms, the KARDEX is available at a central location, ensuring that updated information is always at hand.

3. Organized Data

The KARDEX organizes client data in a structured manner. Information is typically divided into different sections or cards, each dedicated to a specific aspect of the client’s care. This organization helps health professionals quickly find and reference the information they need.

The following are the components of a KARDEX:

1. Client Identification . This section includes basic information such as the client’s name, age, gender, medical record number, and contact information.

2. Medical History . A brief overview of the client’s medical history, including past illnesses, surgeries, chronic conditions, and any known allergies.

3. Current Diagnosis and Treatment Plan. Information about the client’s current medical condition, including the primary diagnosis, secondary diagnoses, and the planned treatment or interventions. This section may also include the physician’s orders and the goals of treatment.

4. Medications. A detailed list of all medications the client is currently taking, including dosages, administration times, and routes of administration. This helps ensure accurate medication administration and avoids potential drug interactions.

5. Nursing Care Plan . Summarizes the nursing diagnoses, expected outcomes, and nursing interventions. This section aligns with the Traditional Care Plan approach, ensuring that nursing care is tailored to the client’s specific needs.

6. Daily Care and Activities. Information about the client’s daily routine, including dietary restrictions, mobility status, personal hygiene needs, and other activities of daily living (ADLs). This helps ensure that all aspects of the client’s daily care are addressed.

7. Progress Notes. A section for health professionals to document observations, changes in the client’s condition, and updates on the care plan. This ensures ongoing communication and continuity of care.

The following are the benefits of the KARDEX system:

1. Improved Communication. By providing a centralized and organized summary of client information, the KARDEX facilitates better communication among health professionals, leading to more coordinated and effective care.

2. Time Efficiency. The concise format of the KARDEX allows health professionals to quickly review and update client information, saving time compared to more detailed and lengthy documentation systems.

3. Enhanced Continuity of Care. The KARDEX helps ensure that all members of the healthcare team are aware of the client’s status and care plan, promoting consistent and continuous care even when multiple professionals are involved.

4. Portability. The portability of the KARDEX system, whether in physical card format or digital form, ensures that essential client information can be easily accessed in various clinical settings, enhancing flexibility and responsiveness in care delivery.

Nursing Discharge & Referral Summaries

Nursing discharge and referral summaries are essential documents completed when a client is being discharged from a healthcare facility or transferred to another institution or home setting. These summaries ensure that the client’s care continues seamlessly and that all relevant information is communicated to the next care provider or community health nurse. The summaries typically include comprehensive information about the client’s condition and care needs.

The following are the key components of Nursing Discharge & Referral Summaries:

1. Description of Client’s Physical, Mental & Emotional State. A detailed assessment of the client’s current health status, including physical conditions, mental health , and emotional well-being. This provides a baseline for the next care provider to understand the client’s overall health.

2. Resolved Health Problems. A list of health issues that have been successfully treated or managed during the client’s stay. This indicates progress made and treatments that have been effective.

3. Unresolved Continuing Health Problems. Documentation of any health issues that remain unresolved and require ongoing attention. This helps the next care provider prioritize and manage these conditions.

4. Treatments to be Continued. Detailed instructions on any treatments that need to be continued post-discharge, such as wound care , oxygen therapy , or other specific medical interventions. This ensures continuity in the client’s care regimen.

5. Current Medications. A comprehensive list of medications the client is currently taking, including dosages, frequencies, and administration methods. This information is crucial to avoid medication errors and ensure proper medication management.

6. Restrictions on Activity, Diet & Bathing. Specific instructions regarding any limitations the client must adhere to, such as restrictions on physical activity, dietary guidelines, and bathing precautions. These restrictions are critical for the client’s safety and recovery.

7. Functional/Self-Care Abilities. An assessment of the client’s ability to perform activities of daily living (ADLs) independently or with assistance. This includes mobility , personal hygiene , dressing , and feeding , providing a clear picture of the client’s self-care capabilities.

8. Comfort Level. Information about the client’s comfort and pain levels, including any pain management strategies that have been effective. This helps in maintaining the client’s comfort post-discharge.

9. Support Networks. Details about the client’s support system, including family, friends, or community resources that can assist in the client’s care. This support is crucial for the client’s well-being and recovery.

10. Client Education Provided. Documentation of the education given to the client about their disease process, self-care instructions, medication management, and lifestyle modifications. Ensuring the client understands their condition and care plan is vital for successful discharge.

11. Discharge Destination. The planned location where the client will be discharged, such as home, a rehabilitation center, or another healthcare facility. This information is essential for coordinating follow-up care and services.

12. Referral Services. Information about referrals to other services or specialists, such as a social worker, home health nurse, physical therapist, or other community resources. These referrals ensure that the client has access to the necessary support and follow-up care.

The following are the importance of nursing discharge and referral summaries in detail:

1. Continuity of Care. These summaries ensure that all pertinent information about the client’s health and care needs is communicated to the next care provider, facilitating a smooth transition and ongoing care.

2. Avoiding Readmission. By providing detailed information and clear instructions, these summaries help prevent complications that could lead to readmission.

3. Client Safety. Accurate and comprehensive discharge summaries help in identifying potential risks and providing strategies to mitigate them, enhancing client safety post-discharge.

4. Empowering Clients. Detailed education and clear instructions empower clients to manage their health effectively, promoting independence and self-care .

Guidelines for Good Documentation and Reporting

Effective documentation and reporting are foundational elements of nursing practice . Accurate and thorough records not only ensure high-quality patient care but also facilitate communication among healthcare providers, support clinical decision-making, and meet legal and regulatory requirements. These guidelines provide a framework for nurses to document and report client care in a consistent, clear, and comprehensive manner.

The primary objectives of these guidelines are to:

1. Enhance Communication. Ensure that all healthcare team members have access to the same accurate and current information about the patient’s condition, treatment, and care plans.

2. Improve Patient Safety. Provide a clear and comprehensive record that helps in identifying and addressing potential risks and errors in patient care.

3. Support Clinical Decision-Making. Offer detailed information that supports informed decision-making by nurses and other healthcare providers.

4. Ensure Legal Compliance. Maintain records that meet legal and regulatory standards, protecting both patients and healthcare providers.

5. Facilitate Quality Improvement. Provide data that can be used for continuous quality improvement initiatives and evidence-based practice.

To achieve these objectives, the following principles should be adhered to:

1. Fact . Information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells

2. Accuracy . Information must be accurate so that health team members have confidence in it

3. Completeness . The information within a record or a report should be complete, containing concise and thorough information about a client’s care. Concise data are easy to understand

4. Currentness . Ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following:

Vital signs
Administration of medications and treatments
Preparation of diagnostic tests or surgery
Change in status
Admission, transfer, discharge or death of a client
Treatment for a sudden change in status

5. Clarity. Use clear and concise language, avoiding jargon and abbreviations that may be misunderstood.

6. Legibility. Ensure that handwritten notes are legible and that electronic records are formatted consistently.

7. Organization . The nurse communicates in a logical format or order.

8. Confidentiality . A confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed

10 Tips on How Nurses Can Improve Documentation

Original article by M. Belleza, RN

One of the tasks that a nurse must accomplish for every shift is their documentation of the patient’s care . This is considered a legal document that can be used in every court of law.

From the traditional handwritten notes until today’s high technology hospital documentation, the important aspects should never be forgotten. Whether it is on paper or a computer, we have to endeavor that we should create a documentation that is reliable, accountable, and precise.

Here are some tips that would make your documentation a stand-out and an example among the rest.

Only chart findings you personally saw or witnessed. During assessment, only document what you heard, saw, or felt, only the hard facts to avoid bias. Subjective opinions are a no-no. If you are documenting something a patient said, it is best to document word for word or verbatim. Some patients may use abusive and foul language , but never include them in your documentation. You can describe the patient’s behavior instead. Never forget to document refusals to treatment, the patient’s reasons, and your actions. You would not want to be responsible for the injury of a patient who refused treatment but you forgot to document it. It might warrant a legal case against you.

Time is everything in the world of nursing. It gives you the power to control what could happen if you put time as your priority. Only document the procedures immediately after you have committed them. This may be a teeny bit hard to follow, especially if you handle more than two patients and you are up to your neck with work. But as much as possible, chart any findings and procedures close to the time after you have done it. Follow hospital protocol if you had a large gap between the executions of the procedure to the documentation.

Not all people are born with amazing handwriting. You may be one of those who are blessed with neat and straight handwriting, yet you may also belong to the ‘unfortunate’ ones who have handwriting that looks like chicken scratch. The only consideration for handwriting is their legibility. It must be readable no matter how disastrous the handwriting is. This would not be a problem for hospitals which have computerized charting systems, but for student nurses , you would be rotated at different facilities so you should be aware of how you chart.

You may want to document everything that happened step by step, but remember that you are not writing a novel. Be accurate with what you are including in your documentation and avoid putting in your opinion about the patient. A precise, short documentation would allow the next nurse to understand quickly what was done before her and would get the idea in a nutshell faster than you could blink your eye .

Any adverse reactions and events that occurred should be documented, pronto! However much we promote the safety of our patients, there are still incidents when the patient develops an allergy to food, medication, or environmental pollutants. Make sure to follow the policies and procedures of the hospital in documenting adverse effects on patients.

Most student nurses may have noticed a lot of abbreviated words when they check the chartings of the staff nurses. Many are confused because they have seen unfamiliar abbreviated terms and because staff nurses are somehow models to student nurses, they follow the same terms when they chart. Be aware of your abbreviations because there are standard abbreviations for medical terms and you cannot just make your own. Different healthcare facilities also have different abbreviations for certain terms, so be sure to check on the list of abbreviations before you venture in abbreviating for your charting. Improper abbreviated terms can be used against you in court if there is an issue regarding your care, and this is the point in our life that we should always, always avoid.

Your charting documents are considered legal papers; therefore, erasures should be avoided. This would be a point of suspicion in court. Make sure that what you are charting is right before you put it on paper. A neat and clean documentation is praiseworthy, and a little positive commendation is also food for the soul and the ego, and for your performance, of course.

The only color advisable to use in legal papers are either blue or black ink. And because your charting notes are legal papers, use these ink colors and nothing else. It also adds uniformity to you chartings. Remember, you are not scribbling on your notepads, so the use of any colored inks besides blue and black is definitely prohibited.

This pertains to following hospital standards and policies regarding proper chart documentation. Never institute your own policies, and never teach your colleagues on what to do if this is not a part of the hospital manual. Anything that you do on a legal premise could be used against you, and you would not want to lose your beloved license, right?

The entries you make on a charting should be confidential. It should not be shared to anyone, even your friends and families. Every patient is entitled to their dose of confidentiality, and a breach of this principle could also put you behind the bars.

As our journey towards the world of nursing progresses onwards, let us never forget the simple things that could make or break our career. Most of us may take documentation for granted, but it is part and parcel of who we are as nurses. These simple things are our stepping stones to a great career, and once we are used to doing things the best way possible, then it would stay the same and your career would be greater than you could ever have imagined.

Berman, A., Snyder, S. J., & Frandsen, G. (2015). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th ed.) . Pearson.
Roques, D. (2024). Source-Oriented Medical Record Format: Overview and FAQ. IntelyCare.

4 thoughts on “Documentation and Reporting in Nursing”

So much great information about charting, guidelines for documentation, nursing care plan, kardex and much more for grasp which is very educative and helps one to become successful in the nursing field.

Hello Barbara,

It’s fantastic to hear that you’re finding the information on charting and documentation so valuable! These are indeed cornerstone skills for success in nursing. By the way, is there a particular aspect of documentation or care planning you’d like to explore further? Or perhaps you have some tips on what’s been most helpful for you in grasping these concepts?

Keep up the great work in your nursing journey!

I would like to see a table that shows how to do in steps of diagnosis

Please check out our Nursing Diagnosis guide .

The Royal Children's Hospital Melbourne

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In this section

Nursing Documentation Principles

Introduction

Nursing documentation is essential for clinical communication. Documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver individualised care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice.

To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistent clinical communication processes across the RCH.

Definition of Terms

EMR : electronic medical record
EMR Review : process of working through the EMR activities to collect pertinent patient details.
The Hub: presents a timeline view of the orders, events, and requirements for each patient the nurse is assigned to and facilitates efficient documentation.
Real time : nursing documentation entered in a timely manner throughout the shift.
Required documentation : minimum documentation required to reflect safe patient care. On admission and at the commencement of each shift, all ‘required documentation’ must be completed to comply with the National Safety & Quality Health Service Standards . There is an expectation that shift required documentation is completed within 3 hours of shift start time.

Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. It is continuous and nursing documentation should reflect this.

Fig 1. Nursing Process

Please note nursing process theory referenced includes an additional phase ‘diagnosis’ which includes identification of problems, risk factors and data analysis, for the purpose of the Nursing Documentation guideline ‘diagnosis’ could occur at any phase and should be documented in real time.

Reference Fig 1: Nursing Theory, the Nursing Process The Nursing Process - Nursing Theory (nursing-theory.org) accessed 2/2/2023

At the beginning of each shift, a ‘primary assessment’ is completed as outlined in the Nursing Assessment Guideline . The information for this assessment is gathered from bedside handover, patient introductions, required documentation (safety checks and risk assessments, clinical observations) and an EMR review and is documented in relevant the ‘Flowsheets’.

Review of the EMR gives an overview of the patient. To complete an EMR review, enter the patients’ medical record and work through the key activities in order. The Patient storyboard has a significant information which can be viewed by hovering over sections. The tabs across can be customised to meet the specific needs of your patient group ( EMR learning resources ). It is recommended that each ward standardises the layout based on their patient population.

The EMR review should include (*indicates essential);

*Patient storyboard - age, treating team, FYIs, infections, allergies, isolations, LOS, weight
*IP Summary - Medical problem list, treatment team, orders to be acknowledged
*ViCTOR Graph - observations trends, zone breaches
*Notes - e.g. admission, ward round, any other useful details (mark all as not new)
*Results Review - recent and pending results (time mark)
*MAR - overdue medications, discontinued, adjust due times for medications
Fluid Balance- input/output and balance
Avatar- review lines/drains/airways/wounds, including, location, size, date inserted
review all active, continuous, PRN and scheduled, discontinue expired,
nursing orders create and manage as required for patient care
Flowsheets - document specific information, ‘last filed’ will show most recent entries, review and manage unnecessary rows e.g. ‘complete’

Patient details are documented in the relevant flowsheets and must include the minimum ‘required documentation’. To ensure required documentation for each patient is complete, use the links from the Hub or other sections of EMR ( EMR learning resources ).

With the information gathered from the start of shift assessment, the plan of care can be developed in collaboration with the patient and family/carers to ensure clear expectations of care.

The Hub is a shift planning tool and provides a timeline view of the plan of care including, ongoing assessments, diagnostic tests, appointments, scheduled medications, procedures and tasks. The orders will populate the hub and nurses can document directly from the hub into Flowsheets in real-time. Orders are visible by the multidisciplinary team.

Management of orders is crucial to the set up and useability of the hub. It must be ‘cleaned up’ before handover takes place - too many outstanding orders is a risk to patient safety.

For more information on how to place and manage orders, click on the following tip sheet: Nursing Hub.

Additional tasks can be added to the hub by nurses as reminders. All patient documentation can be entered into Flowsheets (observations, fluid balance, LDA assessment) throughout the shift.

Nursing staff can also document patient care in narrators or navigators as appropriate i.e. ATD navigators.

Clinical information that is not recorded within flowsheets, narrators or navigators and any changes to the plan of care is documented as a real time progress note.

This may include:

Abnormal assessment, e.g. Uncontrolled pain, tachycardic, increased WOB, poor perfusion, hypotensive, febrile etc.
Change in clinical state, e.g. Deterioration, improvements, neurological status, desaturation, etc.
Adverse findings or events, e.g. IV painful, inflamed or leaking requiring removal, vomiting, rash, incontinence, fall, pressure injury; wound infection, drain losses, electrolyte imbalance, +/-fluid balance etc.
Patient outcomes after interventions e.g. Dressing changes, pain management, mobilisation, hygiene, overall improvements, responses to care etc.
Family centred care e.g. Parent level of understanding, participation in care, child-family interactions, welfare issues, visiting arrangements etc.
Social issues e.g. Accommodation, travel, financial, legal etc.

Implement and evaluate

Progress note entries should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact, outcome and plan for the patient and family.

All entries should be accurate and relevant to the individual patient - non-specific information such as ‘ongoing management’ is not useful.

Duplication should be avoided - statements about information recorded in other activities on the EMR are not useful, for example, ‘medications given as per MAR’.

Professional nursing language should be used for all entries - abbreviations should be used minimally and must be consistent with RCH standards, for example, ‘emotional support was provided to child family’ could be documented instead of ‘TLC was given’. See Medical Acronyms and abbreviations list.

Real time notes should be signed off after the first entry and subsequent entries are entered as addendums.

Example of real time progress note entry:

09:40 NURSING. Billie is describing increasing pain in left leg. FLACC 7/10. Paracetamol given; heat pack applied with some effect. Education given to Mum at the bedside on utilising heat pack in conjunction with regular analgesia. Continue pain score with observations. (Progress Note, sign at the end)

10:15 NURSING. Episode of urinary incontinence. Billie quite embarrassed. Urine bottle given. (Addendum)

14:30 NURSING. Routine bloods for IV therapy taken, lab called- high K+ (? Haemolysed). Medical staff notified, repeat bloods in 6/24. Encourage oral fluids and diet, if tolerated. IV can be removed. (Addendum)

Companion Documents

National Safety & Quality Health Service Standards
Nursing Assessment Guideline
Patient Identification Procedure
EMR Learning Resources
Medical Acronyms and abbreviations list.

Evidence Table

The evidence table for this guideline can be viewed here. -- Coming soon

Please remember to read the disclaimer .

The revision of this nursing guideline was coordinated by Stacey Richards, CNC, Nursing Research and approved by the Nursing Clinical Effectiveness Committee. Updated February 2023.

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

4. Documentation Principles

All health professionals are obliged to document the outcomes of their patient care encounters in a timely and accurate manner. While this is a central premise to producing quality documentation, each organisation will stipulate slightly different documentation guidelines. In this chapter, the general principles for effective paper-based and EHR documentation are presented.

General principles for documentation

General considerations for documenting include:

Documentation should detail information such as assessment findings, risks related to care, the plan of care for the person, modifications to the care plan, interventions performed, and an evaluation of care provided.
Omissions of care need to be documented including the reason why a particular intervention was omitted (e.g., the person refused an intervention).
Documentation should be written or entered contemporaneously—it should occur at or near the time of the event, episode of care or when the encounter took place. Do not wait until the end of your shift to document, and never document prior to providing care.
Documentation must be recorded chronologically.
Documentation must be relevant, individualised, and specific. Avoid being verbose—extraneous information should be omitted.
Do not ‘double chart’: avoid duplicating information on multiple forms including repeating information that has been documented on a care plan or clinical pathway in your progress notes.
Only use abbreviations and symbols that are included on an approved list of the organisation where you are attending professional experience placement. Do not use abbreviations if you are unfamiliar with the organisation’s list of approved abbreviations as there is the risk that an abbreviation may be misinterpreted by others (e.g., the abbreviation LOC could mean ‘level of consciousness’ or ‘loss of consciousness’). If in doubt, write the word or statement in full.
The information must be recorded on an approved clinical record document/program.
If a retrospective entry is made, you must include the date and time in which the event occurred and the date and time that the entry was made.
Avoid criticising others in your documentation.
Never correct another health professional’s documentation, even if it is inaccurate.

Clinical Insight

The FACTUAL mnemonic may assist in applying these core principles to your documentation:

F ocused on the person A ccurate C omplete T imely U nderstandable A lways objective L egible

Tips for improving objectivity

Only document your own observations and actions. Do not document the observations and actions of other health professionals or on their behalf except in situations where you are a designated recorder, such as being a scribe during a Medical Emergency Team (MET) call.
Avoid using words such as ‘fine’, ‘good’, ‘poor’, ‘normal’, ‘large’, ‘abnormal’, ‘regularly’, ‘improved’. Instead, report objective data, specific dimensions, amounts or measurements, and use recognisable systems of measure (e.g., peripheral pulses 2/3 bilaterally in all limbs, 2cm x 2cm bruise, voided 400 mL in the last 6 hours) as this information is more meaningful and quantifiable to others.
Use anatomical landmarks to report findings (e.g., right upper quadrant of abdomen).
Report what you can observe not your opinion or interpretation of the situation (e.g., avoid using vague statements such as ‘appears’, ‘looks like’, ‘seems’; see Table 4 ).
When including others’ accounts of the situation (e.g., the person’s report of pain or nausea), place these statements in quotation marks.



“James is non-compliant.”	“James refused his medications.”
“Jill is miserable.”	“Jill is crying.”

Considerations when documenting by hand

Ensure each page of the document includes the person’s name, date of birth, and unique record number (URN).
Patient identification labels can be used but they must not be placed over the top of an existing label.
Prior to commencing an entry, check that the health record chart you have selected is the correct one by confirming the person’s name, date of birth and URN.
Make sure your writing is legible so that it can be read and understood by others. Consider printing if your cursive writing style is difficult for others to read.
Write in complete sentences and ensure your entry is free from grammatical and spelling errors as such mistakes may lead to unnecessary or missed interventions.
Black, insoluble ink must be used when documenting unless another colour has been stipulated and approved (e.g., when documenting for a specific observation). Black ink is used as it is less like to fade than other colours over time and it also yields the best photocopies.
If there is insufficient space to write a word in a progress note, draw a line and continue your note in the next space. Draw a line to fill in any space after your signature and designation at the end of the note.
If the health record is unavailable at the time of documenting resulting in a gap in the progress notes, draw a diagonal line through the blank page or section to prevent other staff from using this space.
The date should be written in dd/mm/yyyy format and times must be written using the 24-hour clock (also called military time; see Figure 1) .
When documenting vital signs, medication administration, or other procedures, you should note the time that the task was performed.
Each progress note entry should include information about the date and time that the entry was made.
Errors in written documentation must remain visible. Do not scribble over the error or use correction fluid. Unless there is a specific organisational policy, draw a single line through the error and initial it. Some organisations have policies such as writing the word “error” above or near the error and indicating the date and time the correction was made.
At the end of the entry, the author must sign their name followed by their printed surname and initials and designation (e.g., registered nurse, midwife, enrolled nurse, nursing or midwifery student).
Additional details such as information about an external agency or a contact number may be added after the signature where appropriate.
Health professional students must have their documentation witnessed by a registered health professional (e.g., a nursing or midwifery student must have a registered nurse/midwife review and countersign their documentation.


0000	midnight	0800	8 am	1600	4 pm
0100	1 am	0900	9 am	1700	5 pm
0200	2 am	1000	10 am	1800	6 pm
0300	3 am	1100	11 am	1900	7 pm
0400	4 am	1200	Noon	2000	8 pm
0500	5 am	1300	1 pm	2100	9 pm
0600	6 am	1400	2 pm	2200	10 pm
0700	7 am	1500	3 pm	2300	11 pm

Figure 1: The 24-hour clock and standard time

The 24-hour Clock

Understanding the 24-hour clock can be confusing after 1 pm (standard time). Simply add or subtract when converting. For example, if the standard time is 2:15 pm, add 12 hours for the 24-hour clock time of 1415 hours. If you are provided the time of 2230 hours, subtract 12 hours for the standard time of 10:30 pm.

Considerations when documenting in an EHR

EHRs capture your digital identity and time stamps of your activities.
EHRs differ in terms of layout and interface. Structured fields (e.g., vital signs parameters) must be entered according to the specific value format of the field. When entering data into unstructured fields (e.g., progress notes), follow the guidelines for handwritten documentation.
Do not share your password with others.
Do not enter data using somebody else’s password.
Do not walk away from the computer once you are logged in.
If using a template for progress notes, ensure you update it so that it is individualised and provides an accurate description of the care provided for the person.

Explanatory Note

Signing your documentation by hand

Your university will provide further details about what additional information you should include when signing your documentation but generally it will include your signature, full name, university’s name, and year level. Remember to have your supervising registered nurse or midwife countersign your documentation prior to leaving your shift.

Signing documentation in an electronic health record

It is essential to check for unsigned documentation and medications. Most systems will post an alert in the message centre to highlight any unsigned medication or documentation which needs to be signed off prior to the end of the shift.

Documentation in Nursing and Midwifery: Australian edition Copyright © 2022 by Tanya Langtree and Elspeth Wood is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

Do's and Don'ts of Documentation

Good documentation can help nurses defend themselves in a malpractice lawsuit, and keep them out of court in the first place.

Download the infographic Make sure all documentation is complete, correct, and timely. Sloppy documentation practices can be used against a nurse in a malpractice lawsuit. Here are some good tips to follow when charting:

Do's

Before entering anything, ensure the correct chart is being used
Ensure all documentation reflects the nursing process and the full extent of a nurse’s professional capabilities
Always use complete descriptions
Chart the time medication was administered, the administration route, and the patient response
Chart precautions or preventative measures used, such as bed rails
Record any phone call to a physician, including the exact time, message, and response
If a patient refuses to allow a treatment or take medication, document it and be sure to report to a manager and the patient’s physician
Always chart patient care at the time you provide it; it is too easy to forget details later on
If something needs to be added to documentation, always chart that information with a notation that it is a late entry and include the time and date
Always document often enough and with enough detail to tell the entire story

Don'ts

Don’t chart a symptom such as “c/o pain,” without also charting how it was treated
Never alter a patient’s record - that is a criminal offense
Don't use shorthand or abbreviations that aren't widely accepted
Don't write imprecise descriptions, such as "bed soaked" or "a large amount"
Don't chart excuses, such as "Medication not administered because it wasn’t available"
Never chart what someone else said, heard, felt, or experienced unless the information is critical. If absolutely needed, use quotations and properly attribute the remarks
Never chart care ahead of time, as situations often change and charting care that has not been performed is considered fraud

While charting may seem like a menial and repetitive task, demanding the highest quality of documentation for every patient protects all nurses from accusations of malpractice and ensures the best care for all patients.

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Whether you are an experienced nurse or recent grad, documentation can be challenging. Here is some information that can assist with improving your charting and reducing liability risks:

Documentation on trial: 9 ways to protect your agency.

In most states, a patient can wait several years to file a lawsuit and then it can take years before the suit goes to court.

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