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20 Dos and Don'ts for Documentation


Published: 13 November 2016

Cover image for article: 20 Dos and Don'ts for Documentation

20 Documentation Dos and Don’ts

Nursing documentation includes any and all forms of documentation by a nurse or midwife recorded in a professional capacity and in relation to the provision of nursing care. This video collection explains concisely what nursing documentation is and presents 20 fundamental principles of sound nursing documentation.

Each principle is thoroughly explained and is accompanied by examples and practical hints and tips to ensure that your documentation meets these principles, providing accurate records and effective communication.

The 20 fundamental principles covered are:

  1. Don’t erase what is recorded
  2. Record all relevant information
  3. Don’t write critical comments
  4. Don’t leave white space!
  5. Record in black or blue ink
  6. Clarify orders and treatment
  7. Chart your own nursing process
  8. Don’t use ambiguous statements
  9. Only use approved abbreviations
  10. Date/time/sign
  11. Write legibly
  12. Use ‘late entries’ notation
  13. Don’t write in anticipation
  14. Follow organisation policies
  15. Record telephone calls
  16. Complete action and outcomes
  17. Co-signing
  18. Use 24-hour clock
  19. Monitoring
  20. Confidentiality/Security.

These clips are from the Documentation Dos and Don’ts video in a series of eight others on professional nursing topics. Other topics from the series cover:

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Ausmed’s Editorial team is committed to providing high-quality and thoroughly researched content to our readers, free of any commercial bias or conflict of interest. All articles are developed in consultation with healthcare professionals and peer reviewed where necessary, undergoing a yearly review to ensure all healthcare information is kept up to date.

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1 Total Rating(s)

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amy shalala
12 Oct 2019

This is a great resource to touch on on things your are unsure about and to learn new information.

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Megha Raturi
03 Jul 2019