Legal Guidelines for Clinical Documentation

Written by Prince Assandoh-Mensah in 2017

1. Do not erase, apply correction fluid, or scratch out errors made while recording: – Charting becomes illegible; it may appear as if you were attempting to hide information or deface record. Rather draw single line through error, write word ‘Mistaken Entry’ (ME) and initial above it; then record note correctly. Error must be readable.
2. Correct all errors promptly: – Errors in recording can lead to errors in treatment. Avoid rushing to complete charting; be sure information is accurate.
3. Record all facts: – Record must be accurate and reliable. Be certain entry is factual; do not speculate or guess.
4. Do not write retaliatory or critical comments about client or care by other health care professionals: – Statements can be used as evidence for nonprofessional behavior or poor quality of care. Rather, enter only objective descriptions of client’s behavior. For example, chart “ate 100% of …” not “has good appetite”. Client comments should be quoted. For example “c/o chest pain radiating down left arm”. Note that, objective data is to be charted as well in addition to the statement given by the client. The nurse should chart his or her observations: “Skin cold and clammy. Diaphoretic. Vital signs stable”.
5. Do not leave blank spaces in nurse’s note: – Another person can add incorrect information in space. Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at end.
6. Record all entries legibly and in non-erasable ink: – Illegible entries can be misinterpreted, causing errors and lawsuits. Ink cannot be erased. Never erase entries or use correction fluid, and never use felt pen or pencil.
7. If order is questioned, record that clarification was sought: – If you perform an order known to be incorrect, you are just as liable for prosecution as is the physician. Do not record “physician made error”. Instead, chart that “Dr Smith was called to clarify order for analgesic”.
8. Chart only for yourself: – You are accountable for information you enter chart. It must always be clear who performed what activity. Never, chart for someone else (exception: if caregiver has left unit and calls with information). If it is necessary to chat for someone who has left, note the entry as late, what was done, and by whom at what time.
9. Avoid using generalized, empty phrases such as “status unchanged” or “had good day” or “slept well nocte”:– Specific information about client’s condition or case can be accidentally omitted if information is too generalized. Use complete, precise descriptions of care.
10. Begin each entry with date, time and end with your signature and title: – This guideline ensures that correct sequence of events is recorded. Signature shows who is accountable for care delivered.
11. Do not wait until end of shift to record important changes that occurred several hours earlier; be sure to sign each entry.
12. Entries should be concise. Complete sentences are not required. Start each entry with a capital letter, and end the entry with a period even if the entry is a single word or phrase.
13. Refusal of medications and treatments must be documented. A circle is place around the time the medication or treatment is to be given in the appropriate area of the chart. An explanation as to the reason the medication was not given is entered in the nurses’ notes.
14. Chart only those abbreviations and symbols approved by your facility. Information can be misinterpreted or misleading when unfamiliar abbreviations are used. Spell correctly, using proper terminology and grammar.
15. Do not double chart. If something appears on other charts such as Vital signs charts, it does not need to appear on the nurses’ note unless there is an alteration from normal.
16. Do not squeeze information into a space because you forgot to chart it earlier. Add the information on the first available line. Write in the time the event occurred, not the time you entered the information. The words Late Entry can be inserted before charting.

Always remember, Care Not Recorded is considered Care Not Rendered.

Reference

• Eggland, E. T. (1995). Charting master: Using new mechanisms to organize your paperwork. Nursing 95 25(9); 34,
• Potter, P. A., Kerr, J. C., Perry, A. G., & Wood, M. J. (2001). Canadian fundamentals of nursing. Toronto: Elsevier Mosby.
• Smith, S. F., Duell, D., & Martin, B. C. (2004). Clinical nursing skills: Basic to advanced skills. Upper Saddle River, N.J: Pearson Prentice Hall.
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