• Never chart in advance. Even routine events and interactions can go differently than anticipated.
• If you must correct an entry, draw a single line through the error and add the date of the correction and your initials. You may also note "mistaken entry" or "error." Never use correction tape or white-out to change entries or correct typographical errors. Never correct another person's error or indicate your disagreement with the entry in the chart. Discuss any concerns that you may have with a supervisor to ensure that the patient receives the best possible care and the chart remains professional, respectful, and objective.
• Charting should be done as soon as possible after the observation or providing care to reduce the risk that important information will be forgotten. If you must make a late, out-of-sequence, or addendum entry, the following steps will help prevent misunderstandings (Small & Rutherford, 2009):

- Make the entry on the first available line.

- Clearly designate the entry as a "late entry."

- Record the date and time of the late entry.

- Cross-reference the original entry by noting the date and time of the original entry so that the reader can read the notes in the proper sequence.

• Never chart for someone else, actions that you did not participate in, or observations that you did not personally observe. If a colleague contacts you regarding a patient interaction that they forgot to record, you should make the entry as follows:

"04/01/2021 1430, RN Tom Matthews called and reported that at 0530 this morning he observed…."

• Follow the proper method for countersigning notes, and only countersign when required by your institution.

- When reviewing someone else's note, countersign as follows:

"Student nurse name/Entry Reviewed by Jane Doe RN"

- If you actually participate in an activity, countersign as follows:

"Student nurse name/Jane Doe RN"

• All documentation should be objective and free from opinions or assumptions. Rather than stating "the patient was unresponsive," document what you observe through your senses. Never use words like perhaps, maybe, or I think.
• Avoid labeling the patient by using phrases such as drug-seeking, demanding, abusive, or drunk. Instead, your observations should describe the specific behaviors and actions. Rather than saying that the patient was drunk, for example, you can note that you detected the odor of alcohol on the patient's breath.
• All unusual occurrences or patient injuries should be documented objectively without making conclusions or unsubstantiated assumptions. Comments from the patient or others should be indicated with quotation marks. The patient's vital signs, physical and mental condition, subjective complaints, the time of physician notification and arrival, and details of any treatments performed should be noted. You should not make any reference to any incident report that may have been filled out as a result of the occurrence or injury.
• Uncooperative behavior should always be noted, including:

- leaving against medical advice;

- abusing or refusing to take medication;

- not following a diet or exercise plan;

- failing to comply with instructions, such as to remain in bed or ask for assistance;

- failing to provide information impacting care, such as medical history, current medications, or treatments;

- patient or family tampering with monitors, IVs, traction, or other devices;

- failing to attend recommended follow-up visits; or

- bringing unauthorized items into the facility.

• Document any steps taken to protect the patient's safety, such as bed rails were raised, call light placed within reach, or night light was left on.
• Document that the facility's procedure for the safekeeping of valuables was explained and made available to the patient. Patients should be encouraged to send valuables home with family. If they agree, they should sign a statement to that effect. If the patient opts to keep their valuables in an onsite safe or storage locker, all items should be recorded on a receipt with the patient's name and ID number. Each item should be described using objective language (i.e., yellow ring with red stone rather than gold ruby ring). The list should be updated frequently for long-term patients. An updated inventory of valuables and their location should accompany the patient during any transfers.
• Medication administration should be documented as thoroughly as possible and include:

- the date and time,

- your initials,

- the name and dosage of the medication,

- the method of administration, and

- the location if an injection.

• When recording IV infusions, you should note:

- the site of the infusion,

- the type and amount of fluid,

- administration rate, and

- any medications added.

At least once a shift, there should be a note as to the condition of the IV site along with the size and type of catheter.

• When administering pain medication, be sure to note the location and severity of the pain. There should then be a follow-up note as to the effectiveness of the medication.
• Document any medication omissions along with the reason. For example, "fentanyl held pending stabilization of vital signs." Any questions regarding a medication order should be tactfully addressed with the prescriber and in the chart using objective, professional language. If someone else administers medication to your patient, that person should make the chart notation.
• Verbal and telephone orders pose a high risk for error and should be avoided when possible (Institute for Safe Medication Practices, 2017; Moghaddasi & Farahbakhsh, 2017) It should also be noted that documentation of verbal orders, telephone orders, and the reporting of critical lab results verbally or by phone fall under The Joint Commission's "Read-Back" requirement. If a verbal or telephone order is necessary, it should be documented as follows:

- The time and date of the call should be noted.

- The order should be written verbatim and read back to the prescriber to ensure that the information was heard and transcribed correctly.

- Document the entry as T.O./R.B. (telephone order/read back) or V.O./R.B. (voice order/read back) followed by the prescriber's name and your name.

• Documentation of discharge instructions should include:

- any restrictions or requirements for diet or activity;

- a list of medications along with their purpose, dosing, and frequency;

- instructions for wound or skin care;

- specific treatments;

-a list of follow-up appointments; and

- any agency or specialist referrals.

The documentation should indicate that the instructions were given, that the patient and relevant caregivers understood the instructions, and that the patient or caregiver was able to appropriately demonstrate any skills needed for at-home care.