Posted on the CAPT website
www.psychtechs.net
October 30, 2009

Do's and don'ts of documentation

Proper, accurate chart documentation is absolutely vital to individuals’ safety, rehabilitation and continuity of care, as well as important to the best practices of the Psychiatric Technician profession.

DOS

• Check that you have the right chart before you begin writing. • Make sure your documentation reflects the nursing process and your professional capabilities. • Write legibly. • Chart the time you gave a medication, the administration route, and the patient’s response. Chart the patient’s refusal to take medication, if necessary, and report refusals to your supervisor. • Chart precautions or preventive measures used, such as bed rails. • Record each phone call to or discussion with a supervisor, including the exact time and response. • Chart patient care at the time you provide it. • If you remember something important after you’ve finished your documentation, chart the information by stating that it is a “late entry.” Include the date and time of the late entry. • Document often enough to tell the whole story.

DON’TS

• Don’t chart a symptom without also charting what you did about it. • Don’t alter an individual’s record – that’s a criminal offense. • Don’t use shorthand or abbreviations that aren’t widely accepted. • Don’t chart names. Only use initials if identification is absolutely necessary. • Don’t write imprecise descriptions, such as “a large amount.” • Don’t give excuses, such as, “Medication not given because not available.” • Don’t chart what someone else said, heard, felt or smelled unless the information is critical. In that case, use quotation marks and attribute the remarks properly. • Don’t chart care ahead of time. Charting care that you haven’t done is considered fraud.

Compiled with information from NSO

It’s all in the details

Here are some examples of documentation, both bad and good – and best of all!

BAD Client same as above.

GOOD Client continues to be agitated. Redirection provided with favorite activities. Client calms down and then escalates again after an hour. Will call the psychologist.

BEST Client is pacing and screaming. Redirection provided with staff using firm, calm voice as per behavior plan. Redirection successful for a maximum of 45 mins with the following activities and with 1:1 assistance – board game (any), talking and sitting in rockers outside, and preparing his snack. Unable to distinguish antecedent for agitated behavior. Client not able to verbalize or point to anything that is causing or that is in pain. Client is able to have uninterrupted sleep for 7 - 8 hrs every night. No one has observed this client exhibit this behavior before. Called the psychologist to observe client and perhaps have other suggestions for staff.