Tips in Nursing Documentation

It’s a toxic shift for you. You have tons to do including nursing procedures to be performed for each patient and medications to be administered. You also have to assist doctors conducting their rounds and document everything that you have done to each patient. You think to yourself, “Is it really necessary to document?” Yes, it actually is. Aside from performing therapeutic nursing actions, this is one of the most important things to do when you’re a nurse as it may save you and your license when conflict arises. What are some tips that you have to remember when documenting?

  • Check that you have the correct chart before you begin writing.

Check the name first. Make sure that it is the right patient. You wouldn’t want to document something important in the wrong chart, would you? Make sure your documentation reflects the nursing process and your professional capabilities

  • Chart the time you gave a medication, the administration route, and the patient’s response.

Exact time, exact patient, exact route as well as how the patient responds to the drug, especially if it has been given initially.

  • Chart important and critical matters

This may include abnormal vital signs, codes, transfers, change of nursing shift or patient hand offs, taking verbal orders, noting physician’s orders, verifying medication orders. Also, chart any patient care at the time you provide it. Make sure that you document these no matter how busy you seem to be.

  • Report critical values/incidences to the physician within 30 minutes.

Take note of the physician’s response regarding the values. If you can’t reach the resident on duty or even the attending physician, follow the facility’s fail safe plan. As for precautions or preventive measures used, such as bed rails, chart them also. Record each phone call to a physician, including the exact time, message, and response.

  • Chart a patient’s refusal to allow a treatment or take a medication.

Remember that though your main concern is the health of your patient, he/she still also has rights, which includes the right to refuse treatment. If this happens, make sure the patient/folk signs the waver, and document the patient’s refusal. Also, be sure to report this to your manager and the patient’s physician.

  • If you remember an important point after you’ve completed your documentation, chart the information with a notation that it’s a “late entry.”

As the saying goes, “it’s better late than never”. Just put a notation “late entry” beside the information that you forgot to document earlier. Include the date and time of the late entry depending on the institution’s policy and procedure. Document often enough to tell the whole story.

  • Don’t use shorthand or abbreviations that aren’t widely accepted.

Make sure that your documentation is easily readable and understandable. Refrain from using abbreviations especially those that aren’t widely accepted. Also, avoid making general statements as they can be misinterpreted. Consult the nursing policy and procedure for accepted abbreviations.

  • Make sure that your charting is: Objective, Legible, Free of grammatical/spelling errors, Free of errors/erasures, Completed in blue or black ink, and Accurate
  • Do not chart in advance.

You aren’t sure of everything that may happen. The patient’s condition may change within a few minutes.




Liane Clores, RN MAN

Currently an Intensive Care Unit nurse, pursuing a degree in Master of Arts in Nursing Major in Nursing Service Administration. Has been a contributor of Student Nurses Quarterly, Vox Populi, The Hillside Echo and the Voice of Nightingale publications. Other experience include: Medical-Surgical, Pediatric, Obstetric, Emergency and Recovery Room Nursing.

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