The Importance of Proper Nursing Documentation and Record-Keeping: Best Practices

Effective and accurate documentation is an essential part of providing quality patient care as a nurse. Complete, timely and correct documentation in the patient record is crucial for proper communication between nurses, physicians and other members of the healthcare team. Additionally, proper documentation promotes patient safety and positive outcomes. It also serves to protect the legal interests of nurses, patients, and healthcare facilities. In this blog post, we will explore some of the best practices for nursing documentation and record-keeping.


Nurses have a professional and legal obligation to maintain clear, accurate and timely documentation. This includes things like assessment findings, medication and treatment administration, physician orders, patient education and more. Proper documentation is reflective of the nursing care process and provides evidence that the nurse has applied the nursing process correctly. Complete, accurate documentation also demonstrates the nurse’s professional accountability. Insufficient documentation can open nurses and healthcare facilities up to liability risks if an adverse event were to occur. That’s why following best practices is imperative.

Use a Consistent Format

It is important that nurses follow a consistent format for documentation in the medical record. Many facilities have standardized methods for documentation to promote continuity. This may include things like adopting the SOAPIER note format which includes Subjective observations by the nurse, Objective assessment data, Assessment of the current status, Planning for future actions, Interventions performed, Evaluation of how the patient responded and Recommendations for ongoing care.

Other documentation format examples nurses can follow include PIE (Problem/Patient concern, Intervention, Evaluation), ADPIE (Assessment, Diagnosis, Planning, Implementation and Evaluation), and charting by exception where nurses only document deviations from baseline. Following a consistent format improves nurses’ efficiency and ensures they do not miss documenting important elements.

Document Assessments Fully

Nurses should fully document nursing assessments, including the patient’s current status and any changes from previous assessments. The documentation should include all aspects of the assessment – respiratory status, cardiovascular, gastrointestinal, neurological, musculoskeletal, skin integrity, mood/behavior, safety risks and more. Nurses should clearly highlight any abnormal assessment findings. Assessment documentation should also include patient complaints verbatim.

Record Administration of Medications, Treatments Promptly

It is extremely important that documentation of medication, treatment and procedure administration is done promptly. At minimum, this documentation should include the name of the medication or treatment, date and time of administration, dosage given, route of administration, and patient response. Reasons for any delays or omissions in treatment administration should also be recorded.

Document Changes in Condition Immediately

Any significant change in a patient’s signs, symptoms, behaviors or condition must be reported and documented in the patient record immediately. This includes things like a sudden drop in oxygen saturation levels, new onset confusion or agitation, abnormal vital sign changes, suspected adverse medication reactions and more. Prompt documentation ensures the primary care provider is notified so proper intervention can occur.

Avoid Unacceptable Abbreviations

Nurses should avoid the use of unnecessary abbreviations in their documentation. Certain abbreviations have been identified as unacceptable by groups like The Joint Commission due to their association with medication errors. Examples include the use of U for units, QD for daily, MS for morphine sulfate. Spell out words fully or use only approved standard nursing and medical abbreviations to avoid confusion.

Document Care and Communications with Physicians

It’s vital to document all physician notifications, consultations and orders received including date, time, reason and any other relevant details. Nurses should document any care discussions and coordination with other interdisciplinary team members. Doing so provides evidence that proper communication channels were followed. Nurses should also note any failure to carry out physician orders with a full explanation.

Use Nursing Judgment – Avoid Subjectivity

Nurses should use sound nursing judgment when providing their perspectives in documentation. Subjective or editorial comments that portray emotions or value judgments about patients, family members or others in the record are unacceptable. Documentation must remain objective and fact-based.

Practice Proper Chart Corrections

To properly correct an error made in the record, nurses should draw a single line through the error, label it as such, add the date/time and initials, and then rewrite the correct information. Nurses should never fully obliterate or black out errors. Additionally, nurses should not use correction tape, white out products or erasers to correct documentation errors.

Secure Signatures and Dating Properly

Entries made in the patient record must be properly signed and dated. Signatures should include credentials (RN, LPN etc) and be legible so names can be clearly read. Refrain from using initials only. Comply with facility protocols regarding use of written vs electronic signatures.

Maintain Accurate Countersignatures

When assuming care of a patient on a new shift, nurses should counter-sign the documentation from the previous shift indicating they have reviewed the record and are assuming care. Any concerns about previous documentation should be noted. This maintains continuity from nurse to nurse.


Following best practices for nursing documentation promotes patient safety, continuity of care and legal protection for nurses and facilities. Key elements include using a consistent format, recording assessments, treatments, changes in status, physician orders and communications fully, avoiding errors and subjectivity, complying with corrections and signature protocols. Accurate documentation demonstrates the nurse’s professional accountability and commitment to delivering quality care.

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