Do s Use a common vocabulary and accepted abbreviations/acronyms Write legibly Be concise, accurate, and objective Chart patient care

as you provide it Nurses are responsible for assessing and documenting that the patient has an understanding of treatment/interventions so document it. Don t forget that there are two sides to a patient s body. If you document that a patient has pitting pedal edema state which leg or if it s present bilaterally. You need to document the quality of grip strength and foot pulls and if both sides are equal Don ts Do not write subjective findings as if they are objective. Do not say, No pain . Instead say, Denies pain Don t chart a symptom or significant finding without also charting what you did about it Don t chart an intervention without also charting the patient outcome (i.e., suctioned patient, administered pain medications. Accreditation and reimbursement agencies require this. Don t use shorthand or abbreviations that aren t widely accepted Don t write imprecise descriptions such as bed soaked or large amount Incontinence is inability to control bowel or bladder contents. One looses that ability to control those bodily functions when a urinary catheter or rectal tubes is placed. In other words, a patient is not incontinent of urine if that patient has a Foley catheter. The amount of urine in a Foley bag is insignificant if the amount of time is not included. Do not say, Foley bag with 350cc clear yellow urine. Instead say, urine output clear yellow 350cc /4 hours. The same goes for any drainage/secretion.