How to Chart – Nursing Documentation Basics

  1. Date and time each entry.
  2. Indicate both the time the entry is made into the record and the time the observation or
    activity took place.
  3. All entries in the individual’s record should be written or printed legibly in permanent
    black ink.
  4. Do not leave blank lines between entries. Draw a line through unused spaces before and
    after your signature.
  5. Use only abbreviations and symbols approved in agency policies.
  6. All entries in the individual’s record should be written objectively and without bias,
    personal opinion, or value judgment.
  7. The use of slang, cliches, or labels should be avoided unless used in the context of a direct quote.
  8. Interpretations of data should be supported by descriptions of specific observations.
  9. Documentation should be clear, concise, and specific.
    • Don’t use vague terms.
    • Generalizations such as “good”, “fair”, “moderate”, and “normal” should be
      avoided.
    • Findings should be as descriptive as possible including specific information
      about the appearance or findings related to size, shape, and amount.
  10. Correcting errors:
    • Draw one straight line through the incorrect entry,
    • Write “error” above it,
    • Initial and date the correction.
    • Never use white-out, erase, or obliterate an entry in the individual’s record.
  11. Late entries: If you forget to chart something, it may be entered into the record at a
    later time but you must clearly state the date and time the entry is being made and the
    date and time the care or observations actually occurred. The entry should begin with
    the words “Late entry”.
  12. All entries in the nursing notes should be signed. The signature should include the first
    initial, last name and title (e.g., S. Jones, RN).
  13. A record of initials and signatures should be maintained according to facility policy so
    that the person using the initials and signatures used in documentation can be identified.

 

 

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