do not’s of charting in Patient’s Medical Record

Posted by: Rey-Ryan P. Mapiles RN

The do not’s of charting are very important also:

1. Don’t chart a symptom such as “c/o Pain” without also writing what you did about it.
2. Don’t alter a chart….this is a criminal offense.
3. Don’t add information at a later date without indicating that you did so.
4. Don’t date the entry so that it appears to have been written at an earlier time.
5. Don’t use shorthand or abbreviations that are not standard.
6. Don’t write vague descriptions such as “ large amount of drainage”
7. Don’t make excuses, such as “meds not given because not available.”
8. Don’t chart what someone else says unless you use quotations and state who said it.
9. Don’t chart an opinion.
10. Don’t use words that suggest a negative attitude, such as “weird” or “nasty”
11. Don’t chart ahead of time. If something happens it will look bad to go back and make that
correction.
12. Misspelled words and bad grammar are as bad as illegible handwriting.
13. Don’t record staffing problems.
14. Don’t document that an incident report was completed.
15. Don’t record staff conflicts.

Charting care that was not given is fraud. It is punishable by the law and can land you in court, or put your license in jeopardy.

Nursebitz.co ALERT: if you make a mistake, draw a line through the error, and indicate it as an error, and then initial it. Do not write “oops” or “sorry” or draw a happy or sad face in the margin, or any where on the document. This is unprofessional and inappropriate. Don’t leave any blank spaces. Never save a space for a colleague who forgot to chart.