Nursing documentation: defence or downfall

Your documentation can be your defense or your downfall. You didn’t become a nurse to spend hours of time writing in your notes or to have them scrutinised by people trying to find fault in the care you provided. But the reality is that documentation is a necessary part of safe clinical care.
Don’t erase or alter
This is straight forward in hard copy format but it’s easier to delete digital information. It’s really important to apply the same rules to hard copy as we do to digital documentation and avoid altering or deleting content that has already been recorded. If you must alter something, ensure that your edits are clear and legible to reflect transparency, care and decisiveness.
In hard copy this can be done with a line through your text and your initial. In digital form, use the erase or alter function that highlights the altered text in a different colour or records your deletion. Always make a note of deletions.
Record, Record, Record
You’re documenting a record of care, charting the nursing process, showing critical thinking and judgement. So including all relevant information is critical. In an acute situation, the doctor often takes over the documentation when as the nurse, you should include your notes that document your own clinical intervention.
Keeping it nice
Avoid writing critical notes and document a statement of what occurred rather than a judgement of the people involved. Show yourself to be professional and unbiased towards your client and other team members. Quotes are fine to use as a statement of fact that are relevant to care but avoid personal opinion in your documentation that impacts on trust. Clients have access to your notes through freedom of information legislation and should only contain information pertaining to patient care.
Clarify orders and statements
Document clarification of orders or treatment if you are unsure or disagree with them. If you have concerns about best practice you can use your documentation to formalise this. You are accountable for the care and interventions you provide so it is important to record any instructions you receive from a physician that you may be concerned about. Document clearly that you have sought clarification about the treatment that was ordered.
Don’t use hieroglyphics
Abbreviations can appear jargonistic so use them sparingly. Only use abbreviations that are approved by your health facility. Some abbreviations can have more than one meaning across health professions and organisations. For example DC can mean “discharged” or “deceased”. Avoid using abbreviations for external organisations as some governments departments can change their acronyms four times over ten years and this can cause confusion.
Date, Time and Sign everything
This demonstrates sequential care and is often what auditors look for first. Include your patient’s name, code and patient allergies. Ensure every new page includes your patient’s name, client code and all transferable information including allergies. Being each new entry with the date and the accurate time. Sign each entry, adding your title and designation in full. Particularly students should record their year level and education provider they have come through for their placement.
Evaluate any new onset of pain
For example, a patient suddenly complains of a new onset of debilitating headache after he falls and hits head in the hospital. This is documented as a “migraine” although there is no previous history of migraines. 12 hours later, a CT scan reveals brain stem herniation.

References
Ausmed Education. Fast Facts for Nurses and Midwives.
Morales K. 17 tips to improve your nursing documentation. Nursetogether.com