Documentation

Question 1

Factual

Answer 1

Objective ​

Descriptive​

Subjective (quotes)​

NO ASSUMPTIONS OR OPINIONS​

Question 2

No Assumptions

Answer 2

Don’t record a patient fell out of bed unless you actually see him/her fall.​

If you find the patient on the floor. Record that​

If the patient tells you that he fell on the floor. Record that.​

If you heard a thud and went to the room found the patient on the floor, record that.​

Question 3

Accuracy

Answer 3

Exact measurements​

Clear ​

Understandable​

Standard Abbreviations only​

Timed, dated with signature and title​

Correct spelling​

Question 4

Complete

Answer 4

Condition change​

-Onset, duration, location, description, precipitating factors, behaviors.​..

Do not leave blanks. Use N/A​

Communication with patient and family​

​

Question 5

Current

Answer 5

As soon as possible​

Time of occurrence​

Military clock​

Never pre-time,​

Pre-date, pre-chart.​

(this is illegal falsification of the​

record)

Question 6

Organized

Answer 6

Chronological order​

Clear​

Concise​

To the Point​

Complete sentences not needed​

Question 7

Reviewing Pts Chart

Answer 7

Accuracy, clear, comprehensive
-Patient’s needs​

-Nurse’s interventions​

-Patient outcome

Question 8

Terms to Avoid

Answer 8

Accidentally​

Apparently​

Appears​

Assume​

Confusing​

Could be​

May be​

Miscalculated​

Mistake​

Somehow​

Unintentionally​

Normal​

Good ​

Bad​
May indicate the nurse isn’t efficient or proficient ​

It’s okay to say pt miscalculated ​

Don’t use: sort of, might have, probably, seems like ​

If it’s not specific don’t use

Question 9

Dont’s

Answer 9

Don’t document a patient problem without charting what you did about it.​

Don’t alter a patient’s record – this is a crime.​

Don’t write imprecise descriptions, such as bed soaked, large amount…​

Don’t chart what someone else heard, felt or smelled unless information is critical. Use quotations and attribute remarks appropriately.​

Don’t chart care ahead of time. It’s fraud.

Question 10

Paper Charts

Answer 10

Print or Cursive​

BLUE or BLACK Ink​

NEVER Use White-Out​

NEVER Use Erasable Ink​

NEVER Obliterate ​

NEVER erase – NO Pencils ​

Question 11

NEVER

Answer 11

NEVER use labels to describe a patient or patient’s behavior​

Obnoxious, belligerent, rude…​

Question 12

Describe

Answer 12

pts behavior

Question 13

Document

Answer 13

pts refusal, reason for refusal, and what you did about it