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The Importance of Proper Nursing Documentation

Nurses are under tremendous stress under normal circumstances and due to COVID that stress has only increased.  While the demands placed on nursing staffs have increased, it is critical for nurses to ensure that the accuracy and timeliness of completing charting duties does not decrease.

Patient and Nurse

Proper documentation is a critical part of a nurse’s duties and in Nevada a nurse has certain legal obligations related to the creation of a chart record.  For instance, the failure to properly document the administration or wastage of a controlled substance may subject a Nevada licensed nurse to potential disciplinary action.  The same is true if a nurse’s charting is inaccurate or a record is altered.   Chart documentation is not simply a requirement of a nurse’s duties but can also be a proactive way to defend against potential complaints about inappropriate conduct or care raised by an employer, a potential Nevada State Board of Nursing complaint or in a civil malpractice matter.   In essence, if it is not in the record, it didn’t happen, regardless of whether that truly is the case. Below are just a few quick pointers to keep in mind regarding documentation.

Timeliness:  Documentation should always be completed as soon as possible.  While nurses are often allowed the opportunity to complete chart notes at the end of their shift, during a busy shift crucial details can be forgotten in the interim between providing care and documenting that care.  Documentation related to the administration or wastage of a controlled substance should always be done immediately except in the most emergent circumstances.

Accuracy/Completeness:  It is imperative that nursing documentation be accurate and contain sufficient detail not only about the care provided to a patient and the administration of medications, but other details as well.  Such details include communications with other healthcare providers for the patient or interactions with family members.  Try to avoid overusing abbreviations unless they are very commonly used.  Remember you are writing not for yourself but other third parties who will utilize your note.

Correcting Errors/Amending Records:  Under no circumstances should a record ever be altered.  If an error has been made or an amendment to the record is required, such an amendment should be done in accordance with facility/practice policy.  Electronic record systems often have specific requirements as to how to amend a record, be sure to understand how to properly do so.  When in doubt, speak to your charge nurse or director of nursing as to how to correct or amend a patient chart.

While proper documentation can be time consuming and arduous work, it is an absolute necessity for both proper patient care and to proactively defend oneself against potential issues in the future.

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