DOCUMENTATION / CHARTING

CHARTING GUIDELINES


CHARTING
• Is a written method of conveying client information, nursing assessments and interventions, and client response to care.

NURSES! Keep This Mind:
• Make sure the nursing record is stamped with client’s name before you begin writing.
• Write legibly. Always write in permanent ink. Check agency policy for color of ink.
• Begin each entry with the time and date of the recording. End each entry with a signature that consists of your first initial, last name, and abbreviated title.
• Never erase or use white – out.
• If a blank space appears in a notation, draw a line through the blank space so that no additional information can be recorded at any other tine or by any other person.
• Write your notes as soon as possible after giving nursing care.
• Be precise. State your assessments objectively. Report the client’s subjective opinions by quoting directly. Avoid using words that convey judgment or inference – just state the facts.
• Chart the client’s response to interventions
• Use only commonly accepted abbreviations, symbols, and terms specified by the agency.
• Record your teaching
• Review your notes – are they clear and what you want to say.
• Remember that from a legal perspective, if you did not clear it, you did not do it!