Principles of Documentation
specific and definite in using words or phrases that convey the meaning you
that have ambiguous meanings and slang should not be used in charting
objective facts, not your interpretations or opinions
✓ Ate 50% of the food served.
X Ate with poor appetite.
✓ Refused medications.
✓ Seen crying.
✓ = correct
X = Wrong
Place the complaint of the client
in quotation marks to indicate that it is his statement.
Date and Time
Document the date and time of each
It is essential for accuracy in
Record only information that
pertains to the client’s health problems and care.
Accurate complete documentation
will give legal protection to the nurse other health care professional of the
institution and the client.
Client’s name and identification
data must be written on each page of the clients records and entries must be
Document all information necessary
to explain the events in a shift. Anyone reading the document should have a
clear picture of what took place.
Only standard medical and nursing
terminology and community recognized abbreviations and symbols should be used.
Recording of information on the
clients must follow a chronological order charting statements must be logically
organized according to time and content.
Blank spaces are not to be left on
the chart and avoid writing outside the lines of the charting format.
Information within the chart is
often of a personal matter as well as legal evidence of the care provided and
should be available for the necessary health team members only.
Use proper grammar.
signature, place at the end of charting at the right hand margin of the nurses
each entry with your full name and status, e.g. SN for Student Nurse, RN for
All due Medicines are given to Mr.Govind at 8pm by G.Stella
(Mrs.G.STELLA,RN) Registered Nurse
Bed bath given to Mrs. Sivagami at 6 am by R.Grace
( MISS.R.GRACE,SN) Student Nurse
case of error.
§ Correct errors by drawing a single
horizontal line through the error
§ Write the word error above the
line, then sign your signature
§ No ink eradication, erasers or use
of occlusive materials