Documenting Patient Care
Write objective, timely care notes, correct an error the right way, and avoid the wording that makes a note useless.
Table of contents
A care record is how the team knows what happened when they were not in the room. Nurses use it to make decisions, and payers use it to decide whether care was delivered. Lawyers and surveyors also read it, sometimes years later. A good note is short, specific and true. If a task is not in the record, people will assume it was not done.
What You Will Be Able to Do
- Write entries that are objective, specific and timely.
- Use the patient's own words correctly.
- Describe how much help a person needed.
- Correct an error on paper and in an electronic record.
- Avoid the habits that can get a note, or you, in trouble.
What Makes a Good Entry
A good entry says what you saw, heard, measured or did. It does not say what you think it means.
| Weak entry | Better entry |
|---|---|
| Patient did fine today. | Walked 30 feet with walker and one person assisting. Needed one rest. |
| Ate well. | Ate 75 percent of lunch and drank 8 oz of water. |
| Patient seemed upset. | Crying at 10:15. Said, "I miss my husband." Nurse told at 10:20. |
| Skin looks bad. | Red area about the size of a quarter on right heel. Did not turn white when pressed. Nurse told at 2:05 PM. |
"Fine" tells nobody anything. Use measurements, amounts and times. Record intake and output in numbers, not words such as "a lot" or "not much."
Use the patient's exact words in quotation marks when they matter. Write "Patient states" and then quote them. Do not write down your own conclusion in place of what they said.
The Basic Rules
- Chart as you go. Document as soon as you can after giving care, because memory fades quickly. Many employers expect entries within a couple of hours, and some want them before you leave.
- Chart only what you did. Never document care before you give it, and never chart for a coworker.
- Include the time. Use the time format your employer uses, which may be a 24-hour clock.
- Use only approved abbreviations. The Joint Commission keeps a "Do Not Use" list. For example, "U" for units and "QD" for daily have caused harmful errors, so they must be written out.
- Sign every entry with your name and title, or by your own login. Never let anyone else use your login.
- Stick to the facts. Do not blame, complain about coworkers or write opinions.
- Write down refusals. Note what was refused, what the person said, what you offered and who you told.
- Write down who you told. A change in condition is not finished until the note says who was told and when.
Describing How Much Help Was Needed
Saying someone was "assisted" is too vague. Most agencies and facilities use set levels. Use your employer's definitions if they differ.
| Level | What it means |
|---|---|
| Independent | No help or supervision |
| Setup or supervision | You get items ready or watch and cue |
| Contact guard | A hand resting lightly on a gait belt or shoulder while the person does the activity |
| Minimum assist | You do less than 25 percent of the work |
| Moderate assist | You do about 25 to 50 percent |
| Maximum assist | You do more than half |
| Total dependence | You do all of the work |
A note should say the level, the kind of help and any change. For example: "Moderate assist to stand from chair, needed gait belt. More help than Tuesday."
Correcting a Mistake
Everyone makes errors. What you do next matters. Never hide one.
On paper:
- Draw a single line through the error so it can still be read.
- Write "error," then your initials and the date.
- Write the correct information.
Never erase, use correction fluid or scribble over an entry, and never tear out a page.
In an electronic record: Use the system's amendment or addendum tool. The original stays in the record, and the correction shows who changed it and when.
Late entries: If you forgot to chart something, do not squeeze it in or backdate it. Write it as a late entry, using the current date and time, and state the date and time of the event and the reason it is late.
Warning: Falsifying a record, including charting care that did not happen, can lead to firing, loss of your certification and criminal charges. It can also harm the patient.
Common Mistakes
| Mistake | What it costs |
|---|---|
| Writing "fine" or "normal" | Gives the nurse nothing to compare |
| Saving all charting for the end of the day | Lost details and errors |
| Copying yesterday's note | Old information looks current |
| Charting care in advance | A false record if the plans change |
| Writing "patient fell because staff didn't help" | Blame belongs out of the record, so state the facts |
Check Your Understanding
1. You realize you wrote the wrong time on a paper note. How do you fix it?
Draw one line through it, write "error," add your initials and the date, then write the correct time. Do not erase it.
2. It is Thursday and you remember you never charted a skin change you saw Wednesday. What do you do?
Write a late entry with today's date and time, state when you saw it and why it is late, and tell the nurse.
3. Rewrite this entry: "Patient was difficult at lunch and did not eat much."
"Refused meat and vegetables at lunch, saying, 'It hurts to chew.' Ate 25 percent of meal and drank 4 oz of juice. Nurse told at 12:40."
4. A coworker is rushing to leave and asks you to chart for her. What do you do?
Decline. You can only chart what you did and saw, and she must chart her own work.
Key Takeaways
- Write what you saw, heard, measured and did, with numbers and times.
- Quote the patient's own words when they matter.
- Chart as close to the time of care as you can.
- Correct errors openly, and never erase or backdate.
- State the level of help and who you told.
- Only chart your own work, under your own name.