Welcome to Part 2 of our series on nursing documentation best practices. In this installment, we’ll focus on the remaining five principles. These include medication diligence, confidentiality, and legal requirements. We will also cover care transitions and fostering continuous improvement. This ensures your charting is comprehensive, compliant, and contributes to seamless patient care.

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6. Handle Medication Documentation with Diligence

• Five Rights + Documentation: Always confirm and record the right patient, medication, dose, route, time, and right documentation.
• PRN Medications: Note the indication for PRN medications and patient response (e.g., “At 14:00, patient requested PRN albuterol for wheezing; given 2 puffs with spacer; wheezes improved by 14:15.”).
• Refusals or Delays: Document why a patient refused or delayed a medication and any follow-up (e.g., “Patient declined insulin 10 U due to nausea; offered antiemetic; revisited at 15:00; patient accepted dose.”).

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7. Maintain Confidentiality and Professionalism

• Protect Privacy: Only include patient information directly relevant to care. Example: Do not document “Patient refuses treatment because she’s irresponsible.” Instead, document “Patient declined wound dressing change at 10:00. Provided education on importance of care and offered to reschedule.”
• Avoid Public Discussion: Never discuss patient details in hallways, elevators, or phones. Example: Rather than saying “Mrs. A in 302 has severe COPD” in a shared break room, wait to speak privately or use secure messaging.
• Secure Documentation: For paper charts, store them in locked cabinets when not in use. For electronic systems, log off or lock screens. Example: Before leaving the nurses’ station, confirm the EHR session is locked and paper notes are in the charting binder.
• Professional Tone: Use respectful, objective language. Example: Replace value-laden phrases like “non-compliant.” “Patient stated he will take medications every other day due to side effects. An alternative dosing schedule was offered and education was provided.”

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8. Incorporate Regulatory and Legal Requirements

• Consent and Advance Directives: Document informed consent discussions, signatures, and who obtained consent. Record any advance directives or code status, and note any changes discussed with patient/family.
• Incident Reporting: If an event occurs (fall, medication error), chart objective facts about what happened. Include who was notified and the immediate interventions. Do this without admitting liability. Submit a separate incident-report form per facility protocol.
• Signature and Credentials: Sign each entry with your name, credentials (e.g., RN, BSN), and, if required, license number. This ensures accountability and traceability.

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9. Ensure Continuity Across Care Settings

• Handoff Summaries: When transferring patients between units or facilities, write a concise handoff summary. Include critical data like diagnosis, recent changes, and pending tasks. Also list isolation status, allergies, and goals of care.
• Discharge Documentation: Clearly outline discharge instructions, medication regimens, follow-up appointments, symptom monitoring, and whom to call. Also,  confirm patient/family understanding using a teach-back method.
• Interdisciplinary Communication: Note any recommendations or consultations like physical therapy, nutrition and case management in your chart. This ensures the entire team stays informed of collaborative care plans.

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 10. Cultivate a Culture of Continuous Improvement

• Peer Review and Audits: Participate in chart-review sessions where peers review anonymized documentation for completeness and clarity. Discuss strengths and areas for growth.
• Feedback Loops: Encourage colleagues to provide constructive feedback on your charting and offer the same in return. Small tweaks like clearer headings or more timely entries can have a big impact.
• Reflect on Near-Misses: If a communication gap leads to a near-miss or adverse event, review the documentation. Identify where clarity or thoroughness could have prevented the error. Update practices accordingly.

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Conclusion

Together, Parts 1 and 2 of this series outline the foundation and advanced elements of nursing documentation best practices. Nurses should prioritize accuracy, timeliness, and objectivity. Compliance and continuous learning are also important. Doing so allows them to create clear, complete charts. These charts support patient safety, legal protection, and seamless interdisciplinary care.

Interested in downloadable tools? Access our Documentation_Essentials_Toolkit. pdf. It features sample templates and approved abbreviation lists. Use the self-audit checklist to reinforce best practices on every shift.