Communication in Nursing: Documentation and Reporting

Effective communication is the cornerstone of nursing, fostering strong nurse-client relationships and ensuring high-quality patient care. As nurses navigate their roles, they must adeptly manage various phases of communication, from establishing initial connections to executing interventions and ultimately concluding the therapeutic relationship. This article delves into the critical guidelines and phases of nursing communication, offering insights into best practices for documentation, maintaining confidentiality, and overcoming barriers to effective interaction.

Table of Contents

• Communication in Nursing
• Purpose of Communication
• Elements of Communication
• Steps in the Communication Process
• Channels of Communication
  • Auditory Channels
  • Visual Channels
  • Kinesthetic Channels
• Modes of Communication
  • Verbal Communication
  • Nonverbal Communication
  • Electronic Communication
    • E-mail
• Characteristics of Good Communication
• Factors Influencing Communication
• Communicating with Clients Who Have Special Needs
  • Clients Who Cannot Speak Clearly (Aphasia, Dysarthria, Muteness)
  • Clients Who Are Cognitively Impaired
  • Clients Who Are Unresponsive
  • Clients with Hearing Impairments
  • Clients Who Do Not Speak English
• Barriers to Effective Communication
• Phases of Communication
  • Orientation Phase
  • Working Phase
  • Termination Phase
• Reports in Healthcare
• Documentation in Nursing
  • Confidentiality
  • Guidelines for Quality Documentation and Reporting
  • Legal Guidelines for Recording

Communication in Nursing

Communication is the process of sharing information and generating meanings between individuals or groups. It involves conveying meanings through mutually understood signs, symbols, and semiotic rules. As the foundation of human interaction, communication is essential for personal well-being and fulfilling psychosocial needs like love, affection, and recognition. It is a fundamental component of human relationships and is particularly crucial in the field of nursing.

Communication serves as the foundation for establishing a helping-healing relationship. It plays a critical role in influencing behavior and achieving successful outcomes in nursing interventions. Effective communication is essential for the following reasons:

• Establishing Therapeutic Relationships. Communication is the primary means through which nurses build therapeutic relationships with their patients.
• Influencing Behavior. It enables nurses to influence patient behavior positively, leading to improved health outcomes.

Purpose of Communication

Communication is fundamental to human interaction and serves several vital purposes.

• Gathering Information. Collecting data and insights to make informed decisions.
• Validating Information. Confirming the accuracy and relevance of the collected information.
• Sharing Information. Disseminating knowledge, ideas, and updates to others.
• Building Relationships. Developing trust and rapport through meaningful interactions.
• Expressing Feelings. Conveying emotions to connect on a personal level.
• Imagining. Sharing creative and conceptual thoughts to foster innovation and understanding.
• Influencing. Persuading and guiding others to align with certain ideas or actions.
• Meeting Social Expectations. Fulfilling societal norms and engaging in appropriate interactions.

Elements of Communication

Effective communication relies on six essential elements that ensure clarity and understanding.

• Referent or Stimulus. The motivation behind communication, such as an objective, emotion, or need that prompts an individual to communicate.
• Sender or Encoder. The individual who initiates the message, converting thoughts into communicable information.
• Message. The content of the communication, including the information, ideas, or feelings being conveyed.
• Channel. The medium through which the message is transmitted, such as auditory (spoken words), visual (written text, images), or tactile (touch).
• Receiver or Decoder. The person who receives the message and interprets its meaning.
• Feedback. The response from the receiver that indicates whether the message was understood as intended, completing the communication loop.

Steps in the Communication Process

The communication process in nursing involves several critical steps to ensure clear and effective interaction between nurses and patients. Each step plays a vital role in the successful exchange of information, facilitating better patient care and outcomes.

1. Thinking. The communication process begins with formulating the idea or message. The nurse identifies what needs to be communicated, such as instructions for a medication regimen or an update on a patient’s condition. For example, a nurse decides to explain the importance of taking prescribed antibiotics to a patient recovering from surgery.
2. Encoding. In this step, the nurse translates thoughts into communicable forms, such as spoken words, written text, or gestures. This involves choosing the right words and communication methods that the patient will understand. For example, the nurse might use simple language and supportive gestures to explain the antibiotic regimen to an elderly patient who may have difficulty understanding complex medical terms.
3. Transmitting. The nurse sends the encoded message through a chosen channel, such as face-to-face conversation, a written note, or a digital message. The choice of channel depends on the situation and the patient’s needs. For instance, the nurse might sit down with the patient and verbally explain the medication instructions while also providing a written handout for reference.
4. Perceiving. The receiver (patient) perceives the message through their senses, such as hearing the nurse’s words, reading the written instructions, or observing the nurse’s gestures. The patient listens to the nurse’s explanation and reads the provided handout, absorbing the information through auditory and visual channels.
5. Decoding. The patient interprets the message by processing the received information to make sense of it. This step involves the patient’s cognitive abilities and background knowledge. For example, the patient thinks about the nurse’s instructions and relates them to their own understanding of medication schedules.
6. Understanding. The final step is when the patient comprehends the intended message, fully grasping the nurse’s instructions or information. Effective understanding ensures that the patient knows what is expected and can follow through appropriately. For instance, the patient understands the necessity of taking antibiotics at specific times and the importance of completing the course to prevent infection.

Channels of Communication

Effective communication utilizes various channels to convey messages clearly and ensure understanding. In nursing, these channels are particularly important for providing comprehensive care to patients.

Auditory Channels

• Hearing. Perceiving sounds such as conversations, alarms, or equipment beeps. For example, a nurse might hear a patient’s call bell and respond promptly to their needs.
• Listening. Actively interpreting and understanding spoken messages. In a clinical setting, this might involve listening to a patient’s description of their symptoms during an audio conference with other healthcare professionals to ensure accurate diagnosis and treatment.

Visual Channels

• Sight. Observing visual elements like signs, body language, and visual aids. For instance, a nurse might notice a patient’s non-verbal cues, such as grimacing, which indicates pain.
• Reading. Decoding written symbols such as medical charts, letters, or memos. For example, a nurse reads a patient’s medical history and care plan to ensure appropriate interventions.
• Observation. Gaining information through careful observation, such as monitoring vital signs or patient behavior. For instance, a nurse observes a patient’s wound healing process to assess the effectiveness of treatment.
• Perception. Becoming aware of something through the senses, which can include sight, hearing, and touch. For example, a nurse perceives changes in a patient’s condition through a combination of visual inspection and listening to their complaints.

Kinesthetic Channels

• Procedural Touch. Used in medical assessments and interventions. For example, a nurse uses touch to locate a vein for an intravenous injection or to palpate an abdomen to assess for tenderness.
• Caring Touch. Used for comfort and emotional support. For example, a nurse might place a reassuring hand on a patient’s shoulder to provide comfort during a stressful procedure.

Modes of Communication

Communication in nursing can be verbal or nonverbal, each with its own set of principles and techniques to ensure effective information exchange.

Verbal Communication

Verbal communication involves the use of spoken or written words. Effective verbal communication in nursing encompasses several key principles:

1. Pace and Intonation. The manner of speech, including the pace and intonation, significantly influences the impact of the message. For instance, speaking slowly and softly to an excited client can help calm them.
2. Simplicity.Using commonly understood words, brevity, and completeness is crucial. Nurses should select appropriate and understandable terms based on the client’s age, knowledge, culture, and education. For example, instead of saying, “The nurses will be catheterizing you tomorrow for a urinalysis,” it is more appropriate to say, “Tomorrow we need to get a sample of your urine by putting a small tube into your bladder.”
3. Clarity and Brevity. Direct and simple messages are more effective. Clarity involves saying precisely what is meant, and brevity involves using the fewest words necessary. To ensure clarity, nurses should speak slowly and enunciate carefully.
4. Timing and Relevance. The timing of the message is crucial to ensure it is heard and understood. This involves being sensitive to the client’s needs and concerns. For example, a client who is anxious about cancer may not be receptive to explanations about unrelated procedures.
5. Adaptability. What the nurse says and how it is said must be individualized and carefully considered. For instance, if a nurse who typically greets clients cheerfully notices a distressed client, they should modify their tone and expression to convey concern.
6. Credibility. Credibility involves being worthy of belief, trustworthy, and reliable. Nurses build credibility by being consistent, dependable, and honest. They should convey confidence and acknowledge their limitations, such as saying, “I don’t know the answer to that, but I will find someone who does.”
7. Humor. Humor can be a powerful tool in the nurse-client relationship but must be used with care. It is important to consider the client’s perception of what is humorous to ensure it is appropriate and beneficial.

Nonverbal Communication

Nonverbal communication involves the use of gestures, facial expressions, posture, gait, body movements, physical appearance, and body language to convey messages. These nonverbal cues are critical in understanding and interpreting the feelings and attitudes of others.

1. Personal Appearance. The way a person dresses and presents themselves often reflects their feelings and state of well-being. For instance, changes in grooming habits among acutely ill clients, such as a man requesting a shave or a woman asking for a shampoo and makeup, can indicate improvement in their condition. When the symbolic meaning of an object or attire is unfamiliar, nurses can inquire about its significance to foster rapport with the client.
2. Posture and Gait. The way people walk and carry themselves can be reliable indicators of their self-concept, mood, and health. Erect posture and a purposeful stride suggest well-being, while slouched posture and a shuffling gait may indicate depression or physical discomfort. Nurses can clarify the meaning of observed behaviors by saying, for example, “You look like it really hurts you to move. I’m wondering how your pain is and if you might need something to make you more comfortable.”
3. Facial Expression. The face is the most expressive part of the body, capable of conveying a wide range of emotions. While genuine emotions are often reflected in facial expressions, it is also possible to control these expressions to some extent. When the message is unclear, nurses should seek feedback to ensure the intended expression is understood. Nurses must be aware of their own facial expressions and what they communicate to others, especially in sensitive situations. Eye contact is another crucial element, as it can convey attentiveness and sincerity.
4. Gestures. Hand and body gestures can emphasize and clarify spoken words or communicate specific feelings and signals independently of speech. For example, a thumbs-up can indicate approval, while crossed arms might suggest defensiveness. These gestures can significantly enhance the clarity and impact of verbal communication.

Electronic Communication

In modern healthcare, many agencies are transitioning to electronic medical records (EMRs) to document assessments and nursing care. This shift enhances efficiency, accuracy, and accessibility of patient information.

E-mail

Email is a widely used form of electronic communication in healthcare due to its speed, efficiency, legibility, and ability to provide a documented record of messages sent and received. However, it poses confidentiality risks and is not suitable for urgent information, highly confidential details (such as HIV status, mental health issues, or chemical dependency), or abnormal lab data. To mitigate these risks, healthcare agencies establish standards and guidelines to ensure privacy, security, and effective communication, safeguarding patient information and maintaining professional protocols.

Characteristics of Good Communication

Effective communication is essential in healthcare, enabling nurses to interact successfully with patients and colleagues. The following characteristics are key to ensuring clear and impactful communication:

1. Simplicity. Effective communication uses commonly understood words and is brief and complete. This ensures the message is easily comprehensible. For example, instead of saying, “We need to obtain a sample of cerebrospinal fluid via lumbar puncture,” a nurse might say, “We need to take a small amount of fluid from your back to check for an infection.”
2. Clarity. Clear communication involves articulating exactly what is meant. Nurses should speak slowly and enunciate well to ensure the message is understood. As an example, when explaining medication instructions, the nurse could say, “Take one pill every morning with breakfast,” rather than, “Take this daily,” to avoid any confusion.
3. Timing and Relevance. Effective communication requires choosing the appropriate time to convey a message and considering the client’s interests and concerns. It’s important to ask one question at a time and wait for a response before proceeding. For example, if a patient is anxious about surgery, the nurse should wait until after addressing their immediate concerns before discussing post-operative care.
4. Adaptability. Good communication involves adjusting the message and delivery based on the client’s mood and behavior. This personalization ensures the message is received positively and effectively. For example, if a usually cheerful patient seems distressed, the nurse might adopt a more gentle tone and approach, saying, “I see you’re upset today. Is there something specific that’s bothering you?”
5. Credibility. Credible communication is trustworthy and reliable. Nurses must have adequate knowledge about the topic, provide accurate information, and convey confidence and certainty in their messages.

Factors Influencing Communication

Effective communication is influenced by various factors that shape how messages are sent, received, and interpreted. Understanding these factors can help enhance interactions and build stronger relationships.

1. Development. Language, psychosocial, and intellectual development progress through different stages across the lifespan, affecting how individuals communicate and understand information. For example, a nurse may use simpler language and visual aids when explaining a procedure to a young child, compared to a more detailed explanation given to an adult.
2. Gender. Communication styles can vary by gender. People often use language to seek confirmation, minimize differences, and establish intimacy, while others may use language to assert independence and negotiate status within a group.
3. Values and Perception. Values are the standards that guide behavior, and perceptions are individual interpretations of events. Both significantly influence how messages are understood and responded to. A patient’s cultural background might affect how they perceive pain management suggestions, and a nurse must consider these values when communicating treatment options.
4. Personal Space. Personal space refers to the physical distance preferred during interactions. The nurse should be aware of personal space preferences, such as standing closer to a patient when providing emotional support (personal distance) and stepping back during a public health presentation (public distance).
5. Territoriality. Territoriality involves the space and objects individuals consider their own. Respecting these boundaries is crucial for effective communication. For example, the should respect a patient’s personal items and space in their hospital room, asking for permission before moving belongings.
6. Roles and Relationships. The choice of words, sentence structure, and tone of voice can vary significantly depending on roles and relationships, such as between a nursing student and instructor, a client and primary care provider, or a parent and child. A nursing student might use more formal language and structure when speaking to an instructor, while using a more relaxed tone with peers.
7. Environment. People communicate most effectively in comfortable environments. Factors such as noise, privacy, and physical comfort can enhance or hinder communication. A nurse might choose a quiet, private room to discuss sensitive health information with a patient to ensure they feel comfortable and heard.
8. Congruence. Congruence refers to the alignment between verbal and nonverbal messages. A nurse teaching a client how to care for a colostomy should ensure their facial expressions and body language convey confidence and reassurance to match their words.
9. Interpersonal Attitudes. Attitudes convey beliefs, thoughts, and feelings about people and events. Caring and warmth create a sense of emotional closeness, while respect emphasizes the worth and individuality of others. Acceptance involves receiving another person’s honest feelings without judgment, fostering an open and trusting communication environment. A nurse demonstrates respect and acceptance by listening openly to a patient’s concerns about their treatment plan, even if the nurse has a different opinion.

Communicating with Clients Who Have Special Needs

Effective communication with clients who have special needs requires patience, empathy, and appropriate strategies to ensure their needs are met and understood. Here are tailored approaches for different situations:

Clients Who Cannot Speak Clearly (Aphasia, Dysarthria, Muteness)

When communicating with clients who have difficulty speaking clearly, it’s essential to adapt your communication style to facilitate understanding.

• Listen attentively, be patient, and do not interrupt.
• Ask simple questions that require “yes” or “no” answers.
• Allow time for understanding and response.
• Use visual cues such as words, pictures, and objects.
• Allow only one person to speak at a time to avoid confusion.
• Do not shout or speak too loudly; maintain a calm tone.
• Use communication aids such as a pad and felt-tipped pen, magic slate, pictures denoting basic needs, or call bells.

Clients Who Are Cognitively Impaired

For clients with cognitive impairments, creating a supportive environment and simplifying communication can enhance understanding.

• Reduce environmental distractions while conversing.
• Get the client’s attention before speaking.
• Use simple sentences and avoid long explanations.
• Ask one question at a time and wait for a response.
• Be an attentive listener to gauge understanding and comfort.
• Include family and friends in conversations, especially about familiar subjects.

Clients Who Are Unresponsive

Communicating with unresponsive clients requires maintaining respect and providing orientation to help them stay connected.

• Call the client by name during interactions.
• Communicate verbally and by touch to provide comfort and presence.
• Explain all procedures and sensations to keep them informed.
• Provide orientation to person, place, and time regularly.
• Avoid talking about the client to others in their presence.
• Avoid saying things the client should not hear.

Clients with Hearing Impairments

To communicate effectively with clients who have hearing impairments, ensure clarity and reduce environmental noise.

• Establish a method of communication such as pen/paper or sign language.
• Pay attention to the client’s non-verbal cues for understanding.
• Decrease background noise such as television or radio.
• Always face the client when speaking to facilitate lip-reading.
• Consult with family on the best ways to communicate with the client.
• Contact appropriate resources for further assistance with communication aids.

Clients Who Do Not Speak English

When communicating with clients who do not speak English, use translation aids and maintain a respectful tone.

• Speak in a normal tone of voice; shouting can be perceived as anger.
• Establish a method for the client to signal a desire to communicate (e.g., call light or bell).
• Provide an interpreter or translator as needed.
• Avoid using family members, especially children, as interpreters to maintain professionalism and accuracy.
• Develop communication boards, pictures, or cards to aid understanding.
• Have a dictionary available if the client can read in their language (e.g., English/Spanish).

Barriers to Effective Communication

Several barriers can hinder communication:

• Giving an Opinion. This takes decision-making away from the client. It inhibits spontaneity, stalls problem-solving, and creates doubt.
• Offering False Reassurances. This involves twisting the truth into something that sounds reassuring but is indefinite enough that it could mean anything.
• Being Defensive. Defensive behaviors are usually harmful to both the person doing them and those on the receiving end.
• Showing Approval or Disapproval. Expressing approval can be as harmful to both parties as stating disapproval. Offering unnecessary approval on the other hand implies that the behavior being praised is the only acceptable one.
• Stereotyping. Making assumptions about someone because of factors like race, status, beliefs, etc. The use of stereotypes inhibits communication and threatens the relationship between both parties.
• Changing the Subject Matter Inappropriately. This approach shows lack of empathy. Changing the subject halts the progress of the communication process.
• Language barrier. Conflicting language might occur and the communicators might not be able to understand each other. This can happen in any setting because everyone has their own mother tongue language as well as their own understanding of certain words and phrases.
• Time Barrier. Choosing when to approach an individual to talk to about something is very significant because if you do not choose the appropriate time, the person whom you are trying to convey the message might not be engaged in listening to you.
• Lack of knowledge on the topic. Lack of understanding of the topic would make communication complicated for both the sender and the receiver. Normally, people communicate easier when the topic is something that both of them are familiar with.
• Information overload. Processing information takes time and if communication does not go at a pace where both parties can have sufficient time to carry out their thought process, then it will cause communication breakdown as concentration and attention might be haltered.

Phases of Communication

Effective communication in nursing progresses through distinct phases, each essential for establishing, maintaining, and concluding the nurse-client relationship. Understanding these phases helps nurses provide comprehensive and empathetic care.

Orientation Phase

During the orientation phase, the tone and guidelines for the relationship between the nurse and client are established. Despite being strangers, each individual brings preconceptions based on previous experiences, attitudes, and beliefs. The parameters of the relationship, such as the place of meeting, length, frequency, roles, confidentiality, and duration, are clearly defined. Trust, respect, honesty, and effective communication are foundational principles at this stage, as the nurse and client begin to know and trust each other as partners in the therapeutic process. For example, a nurse might explain the purpose of a hospital stay, outline daily routines, and ensure the patient understands their rights and responsibilities.

Working Phase

The working phase is the longest phase, where most nursing interventions take place. During this time, problems and issues are identified, and plans to address them are put into action. Positive changes may occur, though they may alternate with resistance or lack of change. Interaction is crucial in this phase, with the nurse validating the client’s thoughts, feelings, and behaviors. The nurse assists the client in exploring their views of self, others, and their environment, as well as feelings of grief, anger, mistrust, and sadness, and behaviors like promiscuity, aggression, withdrawal, and hyperactivity. Although the content to be explored is chosen by the client, the nurse facilitates the process and continues assessment throughout the relationship. Further problems and needs may arise, requiring the nurse to advocate for the client’s perspectives and priorities in the plan of care. The interactions are designed to ensure the achievement of mutually agreed-upon goals and objectives. For instance, a nurse might help a patient with diabetes manage their condition by setting goals for diet and exercise, monitoring blood sugar levels, and providing education on insulin administration.

Termination Phase

The termination phase, or resolution phase, is the final stage of the nurse-client relationship. This phase occurs when the initial agreement’s conclusion is acknowledged. After addressing the client’s problems or issues, the relationship must be completed before it can be terminated. The ending is based on mutual understanding and a celebration of goals that have been met, resulting in growth for both the nurse and the client. Termination may bring uncertainty, and both parties must recognize that loss can accompany the end of a relationship. Sharing feelings related to the ending of the therapeutic relationship is important, and validating plans for the future can be a useful strategy. Increased autonomy for both the client and the nurse is recognized during this phase. For example, a nurse might review the progress made during care, ensure the patient knows how to manage their health independently, and provide a summary of follow-up plans before discharge.

Reports in Healthcare

Reports are essential exchanges of information among caregivers, ensuring continuity and quality of patient care. They can be oral, written, or audio-recorded. Below are common types of reports used in healthcare:

• Change-of-Shift Report. A comprehensive update provided during shift changes to ensure seamless patient care. This report includes patient status, treatment plans, and any significant events that occurred during the previous shift.
• Telephone Report. Information exchanged via phone, often used for updates or consultations. This type of report is crucial for timely communication between healthcare providers who are not in the same location.
• Telephone or Verbal Orders. Only registered nurses (RNs) are authorized to accept telephone orders, ensuring accuracy and compliance. These orders are typically used in urgent situations and must be documented immediately in the patient’s medical record.
• Transfer Report. Details provided when a patient is transferred from one department or facility to another. This report includes the patient’s current condition, recent treatments, and any specific instructions for continued care.
• Incident Report. Documentation of any unusual or adverse events, such as patient falls or medication errors, to improve future safety and care. These reports are used to analyze incidents and implement measures to prevent recurrence.

Documentation in Nursing

Documentation encompasses any written or printed material relied upon as a record or proof for authorized personnel. It is a vital component of nursing practice, ensuring that patient care is accurately and thoroughly recorded. Effective documentation is characterized by several key attributes.

Accuracy is paramount in documentation, requiring precise and exact recording of patient information. This ensures that every detail of patient care is correctly captured, which is crucial for making informed clinical decisions.

Comprehensiveness in documentation means including all necessary details, from patient history and current condition to treatments administered and patient responses. This thorough approach helps in building a complete picture of the patient’s health status and care needs.

Flexibility is another important aspect, allowing healthcare professionals to retrieve critical data, maintain continuity of care, track patient outcomes, and reflect current standards of nursing practice. Flexible documentation systems adapt to various clinical situations and support efficient information management.

Effective documentation is essential for ensuring continuity of care, saving time, and minimizing the risk of errors. Nurses, as integral members of the healthcare team, must communicate patient information accurately and promptly. Proper documentation prevents fragmented care, reduces task repetition, and avoids delays or omissions in therapy.

Confidentiality

Confidentiality is a cornerstone of nursing practice, rooted in both legal and ethical obligations. All recorded, reported, or communicated data must be handled with utmost confidentiality to protect patient privacy and comply with legal and ethical standards. Nurses must safeguard sensitive information, ensuring that only authorized personnel have access. Here are the key principles nurses must follow to maintain client confidentiality:

• Legal and Ethical Obligation. Nurses are required by law and professional ethics to keep all client information confidential.
• Restricted Information Sharing. Nurses must not discuss a client’s examination, observation, conversation, or treatment with anyone not directly involved in the client’s care.
• Access to Records. Only staff members who are directly involved in a specific client’s care have legitimate access to their records.
• Client Rights. Clients have the right to request and read copies of their medical records. Nurses must facilitate this process while ensuring privacy.
• Protection of Records. Nurses are responsible for safeguarding records from unauthorized access. This includes both physical and electronic records.
• Authorized Use. When using records for data gathering, research, or continuing education, nurses and other healthcare professionals must obtain appropriate authorization according to agency policy.
• Professional Behavior. Maintaining confidentiality is essential to professional conduct. Nurses must protect sensitive and private information diligently.
• Prohibition of Gossip. Sharing personal information or gossiping about clients violates nursing ethical codes and practice standards. Such behavior undermines trust and damages interpersonal relationships.

Guidelines for Quality Documentation and Reporting

Effective documentation and reporting are essential in nursing to ensure accurate communication, continuity of care, and legal compliance. Here are key guidelines to follow with relevant nursing examples:

• Factual. Quality documentation must be based on descriptive, objective information about what a nurse observes through sight, hearing, touch, and smell. Avoid vague terms like “appears,” “seems,” and “apparently,” as they imply subjective opinions rather than facts. For example, instead of writing, “The client seems anxious,” document specific observations such as, “The client is wringing their hands, has a furrowed brow, and is breathing rapidly at 22 breaths per minute.”
• Accurate. Accuracy involves the use of exact measurements and clear, concise data. This precision helps in providing a clear understanding of the client’s condition and care needs. For example, document “Client’s temperature is 101.4°F (38.6°C)” rather than “Client has a fever” to provide a precise measurement.
• Complete. Complete documentation includes all relevant and essential information within each recorded entry. Ensure that all necessary details are provided to give a full picture of the client’s condition and care. For example, “The client verbalizes sharp, throbbing pain localized along the lateral side of the right ankle, beginning approximately 15 minutes ago after twisting their foot on the stair. Client rates pain as 8 on a scale of 0-10. Administered 500 mg of acetaminophen orally. Client reports pain reduced to 4 on a scale of 0-10 after 30 minutes.”
• Current. Timeliness is crucial in documentation. Record entries promptly to ensure they reflect the current status of the client and reduce the risk of errors and duplications. For example, immediately document after administering medication: “Administered 2 mg morphine IV at 14:00 for pain rated at 7/10. Client reports pain relief to 3/10 by 14:30.”
• Organized. Organized documentation presents information in a logical and systematic order. This clarity helps in understanding the sequence of events and interventions. For example, an organized note might describe the client’s pain, followed by the nurse’s assessment, the interventions taken, and the client’s response: “Client reports sharp, constant abdominal pain at 8/10. Assessed abdomen, noted rigidity and rebound tenderness in the right lower quadrant. Informed physician, who ordered an abdominal CT scan. Administered 4 mg ondansetron IV for nausea. Client reports pain reduced to 5/10 after 30 minutes, and nausea subsided.”

Legal Guidelines for Recording

Adhering to legal guidelines in nursing documentation is crucial for ensuring accuracy, accountability, and patient safety. Here are the key principles to follow, with relevant examples:

• Correcting Errors. Draw a single line through any error, write “error” above it, and sign your name or initials. Then, record the correct information. For example, if you mistakenly document a patient’s heart rate as 80 bpm when it is 90 bpm, draw a line through “80,” write “error,” initial it, and then write “90 bpm.”
• Professional Language. Avoid retaliatory or critical comments about the client or other healthcare professionals. Documentation should remain professional and focused on the facts. For instance, instead of writing “The doctor was rude and unhelpful,” document “Discussed treatment options with Dr. Smith.”
• Objective Descriptions. Enter only objective descriptions of the client’s behavior. For example, quote the client’s exact words when documenting their comments to ensure accuracy. An example is writing, “Client stated, ‘I feel dizzy and can’t keep my balance,'” rather than “Client seems unsteady.”
• Prompt Corrections. Correct all errors promptly to prevent misinterpretation that could lead to errors in treatment. For example, if you realize a mistake in dosage documentation, correct it immediately: “Administered 5 mg morphine at 1400 hrs, not 50 mg.”
• Accurate Charting. Avoid rushing when completing charting. Ensure all information is accurate and thoroughly documented. For instance, take time to accurately document vital signs, medications administered, and patient responses rather than hastily summarizing.
• No Blank Spaces. Do not leave blank spaces in the nurse’s notes. Chart consecutively, line by line. If space is left, draw a line horizontally through it and sign your name at the end to prevent tampering. For example, if there is a blank space at the end of a note, draw a line through it and sign your name.
• Legible Entries. Record all entries legibly and in black ink. Never use pencil or felt pen, as black ink is more legible when records are photocopied or transferred to microfilm. This may vary from agency.
• Clarification of Orders. If an order is questioned, document that clarification was sought. This demonstrates diligence and attention to detail. For example, write, “Clarified with Dr. Jones regarding the dosage of insulin; confirmed to administer 10 units instead of 100 units.”
• Accountability. Chart only for yourself and never for someone else. You are accountable for the information you enter into the chart. For instance, do not document for a colleague; ensure entries reflect your own observations and actions: “Wound dressing changed by J. Smith, RN.”
• Specific Descriptions. Avoid using generalized, empty phrases such as “status unchanged” or “had a good day.” Provide specific details about the client’s condition and any changes. For example, instead of “Had a good day,” write, “Client ambulated 50 feet with minimal assistance, reported pain level of 2/10.”
• Timeliness. Begin each entry with the time and end with your signature and title. Do not wait until the end of your shift to record important changes that occurred several hours earlier. Sign each entry to authenticate it. For example, “1300 hrs: Administered 500 mg acetaminophen for headache. J. Smith, RN.”
• Computer Documentation. Keep your computer documentation password secure and never share it. Maintain security and confidentiality by not leaving the computer screen unattended once logged in. For example, log out of the electronic health record system if you need to step away, even briefly, to ensure patient information remains secure.