1) Documentation and charting are integral parts of a nurse's responsibility to advocate for patients and defend nursing actions through demonstrating the standard of care was provided. 2) Nurses must be careful to document critical times such as abnormal vital signs, codes, transfers, and changes of shift, as well as noting orders, procedures, and assessments. 3) Late entries, corrections, and "too perfect" charting can raise doubts, so nurses should follow policy on documentation and use clear, specific language without abbreviations in their notes.

1. RAHIMA MANGELEN, SALENDAB, BSN, R.N,
MEEQAT GENERAL HOSPITAL

2. the nursing profession involves legalities when in
comes to caring patients in all groups. These legal
issues can only straighten when there is accurate
DOCUMENTATION. The common term used in
the field of nursing when it comes to
documentation is CHARTING
The most integral part of the nurse’s responsibility is the
CHARTING FOR NURSES

3. Documentation- in nursing is a key factor in our role and
responsibility as a patient care advocates. It is critical for
determining if the standard of care was rendered to a patient
to defend prior nursing actions. Failure to chart, omissions,
and poor communication are hard to defend
Charting - the act of compiling data on clinical records
or charts (computerized or paper). The charts are
updated regularly to keep physicians and other health
care workers advised of changes in the patient's
condition. The data usually include fluctuations in
temperature, pulse, respiration, other variable factors,
and much more, including all nursing care.

8. Be extra careful when you think you are "too busy."
Be aware of critical times such as:
 abnormal vital signs
 codes
 transfers
 change of nursing shift or patient hand
over (endorsement)
 taking verbal orders
 noting physician’s orders
 verifying medication orders
 date & time of each procedure

9. The nurse must report critical values to the physician within 30 minutes.

10. Avoid general statements.
Beware of general statements that can be
misconstrued . For example, you wrote
“Seen by ER doctor. ” “Seen by Surgeon”
Did you mean:
 Seen by Dr. Moh'd ali?
 Seen & Examine by surgeon
(Seen & examined by
Surgeon Dr. Adel).

11. Late entries and any corrections entered should be per policy and
procedure.

13. Charting patterns including flow sheets will be reviewed. “Too
perfect” charting may raise doubts. Patient assessment such as fall risk
or skin assessments, & new onset of pain must be carefully performed
and documented. Failing to do so is a common error

14. Consult the nursing policy and procedure for accepted abbreviations.
Sign each entry correctly, including date and time. An illegible signature
may lead to all nurses on duty being named in order to “cast a wide
net.” Date and time are crucial when creating a chronology of events.
SAMPLE NURSES NOTES
DATE TIME PROGRESS SIGNATURE
01/01/1434 O7:30H
08:00H
08:45H
09:00H
12:30H
13:00H
10:30H
15:30H
- Received pt on bed awake, conscious and oriented,
afebrile, with IV cannula size 22G in left arm, with
ongoing IV Normal Saline 500 cc at the level of 200
cc, infusing well -------------------------------------------
- V/S checked and recorded -------------------------------
- Seen and examined by Dr. Moh'd Ali with orders
made and carried out -------------------------------------
- Blood for CBC extracted, sent to lab
- Lunch served, ate with fair appetite --------------------
- To keep NPO post-midnight for possible OR
tomorrow ---------------------------------------------------
M.E.
- Fax send to KFH for CT brain --------------------------
- “Late entry” abdominal ultra sound done, report seen
by Dr. Moh'd Ali ---------------------------------
- Closely watched and attended ---------------------
- Endorsed ---------------------------------------------------
A. Al-Harbi
A. Al-Harbi
A. Al-Harbi
A. Al-Harbi
A. Al-Harbi
A. Al-Harbi
A. Al-Harbi
A. Al-Harbi
Amal Al-
Harbi