Accurate & Objective
This type of documentation includes measurable facts rather than personal opinions
What is objective documentation?
Routine nursing care should generally be documented at this time.
What is as soon as possible after care is provided?
The client’s medical record is considered this type of document.
What is a legal document?
When correcting an error in a paper chart, the nurse should draw this through the incorrect entry.
What is a single line?
A nurse should document assessment findings that are relevant to this.
What is the client’s condition?
A client eats 75% of breakfast. This is a better entry than writing that the client “ate well” because it is this type of information
What is specific and measurable documentation?
A nurse gives a PRN pain medication. The medication administration should be documented at this point.
What is immediately after administration?
Documenting care before it is actually performed is considered this serious documentation problem.
What is falsification?
This should never be used to cover up an error in a paper medical record.
What is correction fluid or erasing?
After administering a pain medication, the nurse should document the client’s response during this process.
What is reassessment?
A client says, “My pain is a 7 out of 10.” The nurse should document the statement this way rather than interpreting it.
What is documenting the client’s exact report?
After giving pain medication, the nurse must later document this to show whether the intervention worked.
What is the client’s response or reassessment?
Accurate charting of assessments, interventions, and client responses helps provide this for the nurse in a legal case.
What is legal protection or evidence of care provided?
The original incorrect entry should remain this after a correction is made
What is readable or legible?
When documenting a wound dressing change, the nurse should include wound appearance, drainage, the dressing applied, and this.
What is the client’s response or tolerance?
Instead of charting “the client is anxious,” the nurse should document pacing, trembling hands, and rapid speech because these are this type of findings.
What are observable findings?
A nurse forgets to chart an assessment completed several hours earlier. This type of documentation should be used according to facility policy.
What is a late entry?
When receiving a verbal order, the nurse should perform this action to verify accuracy.
What is read back the order?
If a nurse charts information in the wrong electronic health record, the nurse should follow this.
What is the facility’s correction policy?
After teaching a client how to administer insulin, the nurse should document the teaching and this evidence of learning.
What is return demonstration or client understanding?
A nurse documents “200 mL of partially digested emesis at 1300.” This entry is strong because it includes these three elements
What are amount, description, and time?
Timely documentation helps ensure that the healthcare team has this type of information.
What is current or up-to-date client information?
In legal review, care that was not charted may be treated as though this occurred.
What is the care was not performed?
Changing the original time of documentation to make it appear that charting occurred earlier is considered this.
What is falsification?
“Oxygen applied at 2 L/min by nasal cannula; SpO₂ increased from 89% to 95%” documents both the intervention and this.
What is the client’s response?