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10 Rules for Defensive Documentation

Published on Thu Oct 25, 2012

  • Have a purpose to your entry.
  • Be descriptive.
  • Be concise and precise.
  • Don't leave the next reader in suspense and wondering what happened.
  • Don't leave problems of last shift unaddressed.
  • Describe resident responses and reactions to therapy, med changes, and other aspects of care.
  • Include signature, date, and time.
  • Use legible handwriting, and never skip lines.
  • Make sure every entry corresponds with the resident's care plan.
  • Remember that the chart is a legal document and that it reflects on you and your abilities as a nurse.

    • Source: Karen Merk, R.N., B.S., Clinical Risk Manager for GuideOne Risk Resources for Health Care. For tools you can use to audit your documentation, go to www.goriskresources.com.

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