Documentation Do-Nots

Documentation is clinical communication, not clerical decoration. The record tells the next nurse what the client reported, what you observed, what care actually occurred, how the client responded, and which concerns still require action. A missing, altered, vague, or unauthorized entry can make a safe plan appear complete when it is not. The governing question is not, “How do I make the chart look finished?” It is, “Does this entry accurately represent the care and information for which I am responsible?” Chart only what you personally observed, did, communicated, or received in response. When a finding is abnormal or a client’s condition changes, documentation supports the response; it never replaces assessment, reporting, or escalation.