Lessons · Nursing · documentation: what and when
Documentation: what, when, and how a mistake is corrected
Write what you observed and what you did, after you did it, with the time it happened and your signature; correct an error with a single line through it, the correction beside it, your initials and the date, never by erasing or writing over.
Hone is a place to practise a career, one idea a day. This is one of its lessons, written out in full and free to read without an account.
What it is for
The record is what the next nurse works from and what somebody reads a year later. An entry written in advance is a claim about the future, and a scribbled-out line is a page nobody can stand behind.
How to think about it
Chart facts and figures rather than opinions: what was measured, what was given, what the patient said, what you did. Put the real time of the event on it, not the time you reached the computer, and label an entry made later as a late entry. For a correction: one line through, the right thing beside it, initials and date.
Worked example
1400: 250 mg given by mouth, patient sitting up, dose swallowedWhat happened, when it happened, in plain fact.
Signed by the person who gave itThe person who gave it is the person who signs.
Late entry at 1630 for an event at 1500, labelled as a late entryThe real time of the event, and an honest label on the delay.
Error: one line through, correction beside it, initials and dateThe original stays readable. That is the point of one line.
Your turn
Write how many lines go through an entry that needs correcting.
Correction: line through, then initials and date
Solve one, graded on the server
The trap
Charting a medication before giving it because you are already at the computer. If anything interrupts the round, the record says a dose was given that was not, and the next person has no way to know.