Documentation for patient records is expected to be brief, clear, and accurate. Your state’s Nurse Practice Act provides good general guidelines on the medico-legal purposes and intent of documentation “to record pertinent information including the response to interventions.”

The Basics

Document all visits, phone calls, and email or other correspondence between patient and provider with the:

• Date, reason for, and content of the contact.

• Outcome of visit.

• Plans for follow-up.

More Issues to Document

Clinicians in urgent care settings have a greater responsibility to document issues while under care involving any:

• Sudden decline in patient condition.

• Injuries.

• Medication errors.

• Equipment failure.

• Instructions to patients and family.

• Provider failure to respond.

Why We Document

The main purposes of patient records are to ensure:

• Communication among members of the healthcare team.

• Compliance with standards of care of various accrediting organizations.

• Compliance with standards for reimbursement by a third-party payer.

• Clear and accurate documentation of patient care.

Failure to document pertinent contacts, events, and information and falsifying or making incorrect entries to patient records are causes for suspension or revocation of state licensing.

Language

• Keep sentences brief and objective.

• Report only what occurred and what was said and done.

• Put all patient responses in quotes.

• Refrain from making value judgments (using adjectives such as ate well, seemed relaxed, breathing rapid, normal, slow, etc.)

• Avoid guessing at patient attitudes, beliefs, or state of mind (using words like seemed or appeared.)

Correcting Mistakes

Remembering that all patient documentation can become evidence in future legal actions is important. The main goal of all documentation is to present a clear, accurate, and complete picture of the patient’s presentation and how it was treated.

Charting errors occur and may be rectified by marking the mistake with a slash, recording the time and date of the discovery, and designating new notes as “late entry” with the time and date. More extensive errors involving recording to the wrong chart, erroneous transcription of orders, or missing information may require more investigation or supervisory assistance to fully rectify. Never knowingly leave a chart incomplete or incorrect.

More Information

For more detailed guidelines, refer to these resources:

• Principles of Nursing Documentation

• The Do’s and Don’ts of Documentation

‍Presentation by Alexa Schneider and the University of Rochester Medical Center