• Chance Reaves

The 10 Commandments of Nursing Documentation

Updated: May 17, 2021

When I became a nurse, I felt like many of you when it came to nursing documentation. I felt lost. Almost as if there was a sense of "I need to document everything,"

....accompanied with, "Should I chart this?"...

...followed by "This doesn't feel right to note this."

It would have been so much easier on me (especially my OCD, Type-A, ICU Nurse personality) to have had a solid set of 10 or so golden rules of nursing documentation.

Well, the wait is no more!

I present to you...

The 10 Commandments of Nursing Documentation

I - Follow Your State's Nursing Practice Act

If you don't already know, part of becoming a nurse is to follow what is known as a Nursing Practice Act. The act is a series or set of rules that outline the rules and responsibilities of nurses in a state - most importantly, establishing the Standard of Care.

When it comes to nursing documentation, one of the main goals is to document the care you provide to patients. When you complete a task, give medication, or complete an assessment, the medical record should reflect that. And as a result, all of your charting should be aligned with the Standard of Care in your Nursing Practice Act. In fact, many state NPAs outline the requirements of documentation (not all though!). Check out this interactive map to take you directly to your state NPA.

When in doubt, remember this...

Standards of Care = What You Should Do For A Patient = What You Should Chart

II - Default to your Organization's Standard

The beauty of working for a hospital system or provider is that 99.999% of them have legal counsel to ensure regulatory compliance and avoid litigation. They really do spend a lot of money and time with lawyers and other compliance officers narrowing down what should be done in your facility.

And in many cases, the documentation standards are no different. Purchasing and using electronic medical record software is expensive, and most organizations want to do right by themselves, their staff, and most importantly the patient. Because of this mindset, they often establish a minimum standard for charting.

As a default, you should use whatever standard they set. If you are being required to chart or document something that flies in the face of other laws or regulations or is unclear, it may be time for a review. Bring these ideas to the table in a positive, optimistic way and demonstrate a benefit for all stakeholders. But as a general rule, you should follow the charting and documentation requirements set by your organization, at a minimum.

III - Don't Violate HIPAA

This one seems like it doesn't need to be said...but I'm going to say it.

Don't violate HIPAA. Or to be more clear, don't simply document something as "an organizational standard" if you are being asked to violate HIPAA and patient privacy.

As an example, if you are being asked to sign off or attest to another nurse's assessment, but you never actually assessed the patient, you may be putting your license and patient safety on the line. Remember, reviewing a patient's medical record is only required (and allowed) if you are providing direct care to that patient. So if you're being asked to sign off on something that you didn't do, start digging in and finding out the root cause of why this is required. It's important to follow regulations, but we don't want to violate federal laws like HIPAA in order to check off a task box.

IV - Don't Double Document

I have an entire blog post on this, but the big takeaway is that double documenting puts you in a position to contradict yourself.

One of the big purposes of documentation is to provide clear communication across a team. And if you inadvertently write two different things for the same care, you muddy the waters. Check out the post for more info!

V - Chart Habitually

When I say, "chart habitually," I mean you need to document the same way, for every patient, every time. Doing this essentially creates good habits and makes it feel glaringly obvious when something is missing. It feels like wet socks (for those of you who don't know me, this is probably my number one pet peeve, outside of my misophonia). It becomes this hyperfocused annoyance that I can't rectify until I can get out of them.

By charting the same way every time (whether it's reviewing the Kardex, giving medications, or charting an assessment or workflow), if you forget something, you can't move on until it's fixed. So, create a good habit and workflow to make your charting smooth, efficient, and most importantly, complete.

VI - Don't Copy & Paste

This is also another one of those things that go without saying. You should never copy and paste another nurse's or clinician's notes. Many of the EHRs today have the ability to notate the copy/paste function. And when you copy and paste, what you are doing is grabbing the information from the record as if it were your own. It's plagiarism at a minimum, and falsifying documentation at a max. You never want to have the integrity of your documentation questioned, so copying and pasting a note does nothing but jeopardize your patient's care, your license, and your employer's credibility.

VII - Make Your Nurse's Note a Bob Ross Painting

I love Bob Ross. Simply my favorite artist. But one of his most endearing traits (outside of Happy Little Trees), was his enormous talent as an artist.

But nurse charting can be like that painting. The canvas he painted on is the electronic health software, and his paints and brushes are the features inside the software. It's now your canvas. Remember that we because we don't double document, we have to utilize nursing notes (or nurse narratives) to explain what's happening with our patient. If there is a place somewhere that you can document something (like a spreadsheet somewhere), that is the default location. The purpose of that narrative is to explain and paint that picture of the patient that just doesn't fit anywhere else.

Like painting, proficiency comes with time. So be patient and don't expect to get this perfect at the beginning.

VIII - Chart Objectively

Subjective - What the patient (or "subject") says they are experiencing.

Objective - What you are experiencing.

When we chart, we need to chart objectively. The reason we do this is that we have to describe what we are seeing, through our specialized nurse lenses. This gives credibility to the documentation and provides a more clear picture to other providers.

Here are a few examples...

Don't say..."the patient is in pain."

Instead, say..."the patient states their pain level is 4/10."

Don't say..."the patient is hearing voices."

Instead, say..."the patient states that they are hearing voices of people not in the room."

Don't say..."the patient is nauseated."

Instead, say..."the patient states that they are nauseated."

IX - Don't Use Crazy Abbreviations

Remember, we are really focusing on creating a clear picture of our patients. But if we use random abbreviations to save us three keystrokes, and cause a 15-minute discussion with the provider about what you meant, did we really save time? Absolutely not. The beauty of medical terminology is that there are many abbreviations/acronyms/initialisms that are commonly used (i.e. EGD for esophagogastroduodenoscopy), but the important thing is that there are two big rules to follow here:

  1. Make sure it a commonly standardized abbreviation in your organization

  2. Make sure you avoid any that are on The Joint Commissions "Do Not Use" List (hint: we have a free download of that document here)

X - Familiarize Yourself With the Software

As a techy and trainer of electronic software, I can't stress this enough. Many EHRs provide the opportunity to use training software or environments to learn how to use the software. In fact, many studies have shown that it takes about 6 months to become proficient and comfortable at using an EHR. So, if the opportunity presents itself, utilize the resources of your hospital or organization to help yourself and your patients.

The goal of this website is to give you the ultimate resources to improving your practice of documentation. Please remember to always practice an abundance of caution and seek answers regarding your documentation's legality with your organization or through your state board of nursing.

This site is run completely free of charge. If this site helped you in your documentation journey, and you have a few quarters lying around in couch cushions, it's so helpful to keep this site up and running! Thanks for your donation!

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