Chapter 10: Informatics and Documentation; Table 10.1

Question 1

Do Not Erase, Apply Correction Fluid, or Scratch Out Errors Made While Recording

Answer 1

• Charting becomes illegible; appears as if you were attempting to hide information or deface record
• Draw a single line through error, write word error above and initial and title. Then record note correctly

Question 2

Do Not Write Retaliatory or Critical Comment About Patient or Care by Other Health Care Professionals

Answer 2

• Statements can be used as evidence for nonprofessional behavior or poor quality of care
• Enter only objective descriptions of patient’s behavior, patient comments should be quoted

Question 3

You Need to Add Patient Information

Answer 3

• New information is acquired
• Write the date and time of the new entry on the next available space and include and follow facility format
• You forgot to chart during a shift
• Write current date and time in the next available space and rationale for delay, label entry “late entry” and follow the format established by your facility

Question 4

Correct All Errors Promptly

Answer 4

• Errors in recording can lead to errors in treatment

- Avoid rushing to complete charting; be sure that information is accurate

Question 5

Record All Facts

Answer 5

• Record must be accurate and reliable

- Be certain that entry is factual; do not speculate or guess

Question 6

Do Not Leave Blank Spaces in Nurses’ Notes

Answer 6

• Another person can add incorrect information in space

- Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at end

Question 7

Record All Entries Legibly and In Black Ink

Answer 7

• Illegible entries can be misinterpreted, causing errors and lawsuits; ink cannot be erased; black ink is more legible when records are photocopied or transferred to microfilm
• Never erase entries or use correction fluid and never use pencil or pens with erasable ink

Question 8

If Order is Questioned, Record the Clarification was Saught

Answer 8

• If you perform an order known to be incorrect, you are as just as liable for prosecution as the physician or health care provider is.
• Do not record ‘physician made error’ instead chart that ‘Dr. Smith was called to clarify order for analgesic’

Question 9

Chart Only For Yourself

Answer 9

• You are accountable for information you enter into chart

- Never chart for someone else

Question 10

Avoid Using Generalized, Empty Phrases Such as ‘Status Unchanged’ or ‘Had a Good Day’

Answer 10

• Specific information about a patient’s condition or case can be deleted accidentally if information is too generalized
• Use complete, concise descriptions of care

Question 11

Begin Each Entry with Date and Time and End with Your Signature and Title

Answer 11

• This guideline ensures that correct sequence of events is recorded; signature documents who is accountable for care delivered
• Do not wait until end of shift to record important changes that occured several hours earlier; be sure to sign each entry

Question 12

For Computer Documentation Keep Your Password to Yourself

Answer 12

• Maintains security and confidentiality

- Once logged onto computer, do not leave computer screen unattended and log out when you are finished charting