Nursing Documentation Best Practices: What to Do and What to Avoid

Accurate nursing documentation is essential to patient safety, continuity of care, and healthcare risk management. A patient's medical record provides a timeline of assessments, clinical observations, interventions, communications, and responses to treatment. When a medical malpractice claim arises, nursing documentation may become critical evidence in evaluating the care provided.

Understanding nursing documentation best practices can help nurses avoid common documentation errors, communicate changes in a patient's condition, and create a clear, factual record of care. On the other hand, incomplete assessments, missed physician notifications, subjective comments, and improperly documented late entries can create significant challenges for healthcare organizations.

This month, LHA Trust Funds explores three real-world claim scenarios that demonstrate how nursing documentation can affect patient care and liability exposure. Learn what nurses should document, which common mistakes to avoid, and how healthcare organizations can strengthen documentation practices to support safer care.

6 Nursing Documentation Best Practices

Proper nursing documentation creates a clear, accurate record of a patient's condition and the care provided. Consistent documentation practices also support communication among healthcare professionals and help organizations evaluate the quality and safety of care.

Nurses should follow their organization's specific documentation policies, applicable professional standards, and relevant legal requirements. The following nursing documentation best practices can also help promote accurate, complete, and timely medical records:

1. Document Assessments & Changes in Condition: Record relevant assessment findings, clinical observations, and changes in a patient's condition. Documenting these findings helps establish a clear picture of the patient's status over time.
2. Record Interventions & Patient Responses: Document the nursing care provided and the patient's response to interventions. Include relevant follow-up assessments and any additional actions taken when the patient's condition changes.
3. Document Physician Notifications & Escalation: When a patient's condition warrants notification of a physician or another member of the care team, document the communication according to organizational policy. Include relevant information about the notification, instructions received, and follow-up actions.
4. Use Objective, Factual Language: Medical record documentation should reflect observable findings, verified information, and specific actions taken. Avoid speculation, blame, personal opinions, or derogatory comments.
5. Complete Documentation Promptly: Timely documentation helps maintain an accurate clinical timeline and supports continuity of care. When a late entry is necessary, follow organizational policy for identifying and completing the entry.
6. Follow Established Documentation Policies: Healthcare organizations should provide clear guidance on nursing assessments, handoffs, adverse events, physician notifications, and corrections or late entries in the medical record.

Using the FACT acronym can help nurses remember and adhere to these practices effectively:

• Factual: Stick to fact-based statements that support the clinical concern, without speculation or personal opinions.
• Accurate: Ensure numerical values, times, and other details are correct and supported by evidence.
• Complete: Include all relevant information about the clinical concern.
• Timely: Complete documentation promptly and according to organizational policy to reduce the likelihood of late entries or gaps in the record.

Scenario 1: Patient Advocacy

The patient presented to the emergency department with signs and symptoms of a possible stroke. The patient and the family member present at the time of triage and initial exam were unable to provide context or history for the patient’s symptoms.

Before obtaining a CT scan, the physician discussed the patient’s status with the on-call neurologist. An order was given to the nursing staff to administer tissue plasminogen activator (TPA). The nurse receiving the order documented a dispute with the ordering physician in the patient’s chart about administering TPA, expressing her concerns. The ER director was included in the discussion regarding the concerns about administering TPA to this patient without the CT scan results.

The ED physician stood behind his care plan decision based on the neurologist’s consultation. He adamantly ordered and obtained consent from the patient’s family member to administer the TPA.

When the CT scan results were available, they revealed the patient had an aneurysm in the artery under his collarbone. TPA was immediately discontinued, and the patient was transferred to a higher-level care facility.

There is a balance between advocating for patients and creating a discourse between care team providers when considering liability exposures. Nursing staff often face criticism in a claim for a failure to advocate for their patients. Ultimately, the decisions regarding a patient’s care are the physician’s decisions. However, nurses are responsible for their actions and the consequences of the implementation of care. As a result, they are expected to use their critical thinking skills in evaluating physician orders.

In this situation, the nurse was trying to advocate for the patient by voicing concerns and escalating them to leaders when the nursing and medical staff disagreed on the best course of action. A nurse's first responsibility is patient safety. Each organization should have a policy to describe how conflict resolution in situations such as this should be handled.

If the disagreement is not resolved and a nurse makes the decision to refuse a portion of the patient’s care, that nurse should be expected to communicate their decision to the treatment team expeditiously to minimize risks to the patient. This communication involves documenting facts and specific steps taken directly relating to patient care into the patient record, as well as steps taken to escalate the concerns.

Care must be taken to avoid placing blame or derogatory comments in the medical record when documenting patient advocacy issues. While this type of situation can cause emotions to run high, it's important to stick with the FACT acronym when documenting in the medical record.

Scenario 2: Failure to Assess

Nurses are frequently involved in claims regarding allegations of failure to assess and notify the physician. A recent claim scenario involves a wound care nurse who assessed a patient’s foot for possible development of a new ulcer and failed to document her findings or report them to the attending physician. The patient’s foot deteriorated rapidly, resulting in an eventual amputation.

Complete nursing assessments of patients should be done at least at the beginning of each shift and additionally, according to the healthcare facility’s policy. Findings from the assessment should be communicated to the physician, as well as passed along at the handoff of patient care, to ensure the continuity of care.

Although the wound care nurse in this situation failed to report or document any findings about the new pressure ulcer, every nurse in charge of this patient's care had the same responsibility to complete a skin assessment on the patient. All changes in the patient's condition — which include skin assessments — should be documented in the medical record and reported to the physician.

Nursing assessment documentation helps establish a baseline for a patient's condition and creates a record of changes that may require additional evaluation or intervention. When an assessment reveals a new symptom, wound, change in skin integrity, or other concerning finding, nurses should document the relevant observations and communicate concerns to the appropriate members of the care team. Any follow-up assessments, notifications, and interventions should also be documented according to organizational policy.

Complete and timely nursing documentation supports continuity of care by helping other healthcare professionals understand the patient's condition and the actions taken in response to changes.

Scenario 3: Failure to Monitor

In another case, a patient suffered a fall out of her bed in the ED. The nurse documented the fall and that the patient suffered no obvious injuries. Existing orders were continued.

The following morning, the physician rounded on the patient. It was noted that the patient had increasing mental decompensation. During that exam, a family member told the physician that she had fallen out of bed the evening before. The physician had no prior knowledge of the patient’s fall during the previous shift. When the nurse was contacted about the fall, he went into the chart and made a late entry stating that he had notified the physician of the fall, and no new orders were given.

It's a common misconception that adverse events should not be documented in the medical record. Events that occur should absolutely be documented in the patient's record. However, the facts of the situation should be documented, not insinuations or opinions.

For example, if you did not actually see the patient fall, you would not document that the patient fell. If you walked into the room and the patient was sitting on the floor and said they fell, that's exactly what should be documented with the words “the patient stated” in quotations. This would represent the facts of the findings.

Incomplete or lack of adverse event documentation is a red flag that can:

• Demonstrate incomplete patient care.
• Demonstrate noncompliance with organizational policies.
• Support allegations of negligence.
• Support allegations of fraud.

The response to a patient’s fall should be outlined in your fall prevention policy, and the safety of the patient should always be the top priority. A patient assessment immediately following the occurrence should be documented, including actions taken to treat or care for the patient. Notification of the physician should always be included in the response and documented in the record.

If a fall is unwitnessed by staff or it is unknown if the patient hit their head during a fall, serial neurological assessments should also be implemented to ensure no mental deterioration. Neurological assessments are a nursing intervention that can be added to the care plan according to an assessed need rather than a physician's order.

When documenting an adverse event or an unanticipated outcome, you should include:

• “Known facts” about the event.
• Physician notification.
• Care given in response.
• Effect/injury to the patient.

Do not include:

• Subjective feelings or beliefs.
• Speculation or blame.
• References to incident report forms.
• References to risk management.

In this case, the nurse also documented a late entry regarding the adverse event. Late entries should be avoided when possible. When they are necessary, follow the organizational policy on how to appropriately document the entry into the medical record. Late entries are a red flag in documentation because they give the impression that the care team is trying to cover something up.

Best Practices for Late Entries in Medical Records

Although timely nursing documentation is preferred, circumstances may arise in which a nurse must complete a late entry. When this occurs, the entry should follow the healthcare organization's documentation policy and applicable professional requirements.

A late entry should accurately reflect the care provided and the information known to the nurse at the time. It should be clearly identified as a late entry and include the actual date and time of the entry, along with the relevant date and time of the event or care being documented, as required by organizational policy.

Nurses should never backdate documentation, alter the clinical timeline to make an entry appear contemporaneous, or include information they cannot substantiate. If an error or omission is identified, corrections and additions should follow established procedures that preserve the integrity of the medical record.

Clear, accurate late entries help maintain a reliable clinical record and support continuity of care.

Nursing Documentation Matters. Stay Ready with LHA Trust Funds.

Accurate and complete nursing documentation is key when it comes to defending claims. Good nursing documentation practices within your healthcare facility will help your patient care documentation stand up to scrutiny.

Interested in nursing documentation training? LHA Trust Funds offers on-site training developed specifically for nurses that stresses the importance of proper nursing documentation in the medical record.

Frequently Asked Questions About Nursing Documentation

Why is nursing documentation important?

Nursing documentation creates a record of patient assessments, clinical observations, interventions, communications, and responses to treatment. Accurate and complete documentation supports continuity of care, patient safety, and the evaluation of care when a medical malpractice claim arises.

What should nurses document in a patient's medical record?

Nurses should document relevant assessment findings, changes in a patient's condition, care provided, patient responses, physician notifications, and follow-up actions. Documentation should be timely, objective, accurate, and consistent with organizational policies and applicable professional requirements.

What are common nursing documentation mistakes?

Common documentation concerns include incomplete assessments, failure to document changes in a patient's condition, missed or undocumented physician notifications, subjective or speculative comments, and improperly handled late entries. These issues can create gaps in the clinical record and raise questions about the care provided.

How should nurses document a patient's fall?

Nurses should follow their organization's fall response policy and document the known facts of the event, relevant patient assessment findings, care provided, physician notification, and the patient's condition following the incident. Documentation should distinguish between directly observed events and information reported by the patient or others.

How does nursing documentation affect medical malpractice claims?

Nursing documentation may be reviewed during a medical malpractice claim to evaluate patient assessments, clinical decisions, communications, interventions, and follow-up care. Incomplete or inconsistent records can create questions about whether appropriate care was provided and whether concerns were communicated promptly.

About The Authors

Jamie Lamb
Director of Claims Operations, LHA Trust Funds

Jamie Lamb began her career in claims in 1997. Her experience includes handling multi-line claims in the areas of general liability, medical malpractice, automobile liability, commercial and personal property, excess and umbrella policies, and professional liability. Her experience comes as a former Manager and Litigation Specialist for the American National family of companies. She has been highly involved in the education and training of both internal and external customers her entire career. Ms. Lamb attended both Evangel University in Springfield, Missouri, and Loyola University in New Orleans.

Stacie Jenkins, RN, MSN, CPSO
Vice President of Patient Safety and Risk, LHA Trust Funds

Stacie Jenkins is a registered nurse with a master’s degree in nursing informatics. She has more than 20 years of experience in healthcare, working in patient care and quality/performance improvement positions. As the Vice President of Patient Safety & Risk at LHA Trust Funds, she works closely with hospital administrators, risk managers, and nursing staff to improve patient safety and establish best practices. She conducts on-site assessments and gives presentations designed to help clients address their patient safety risk management challenges.