Guidelines for Nursing Documentation I

Nursing documentation guidelines include the following:

A factual record comprises subjective and objective information about what the nurse sees, hears, touches, and smells.

Subjective data is information the patient verbalizes and is documented using the patient's exact words within quotation marks.

Objective data refers to information that can be seen, heard, or felt by someone other than the person experiencing it.

Consider a patient who reports chest pain and breathlessness, which is subjective data. This would be documented as "Patient reports chest pain and breathlessness." The nurse observes and documents objective data points: fluctuating blood pressure, heart rate, and respiration.

Next, to establish accuracy, use exact measurements, which help to show if the patient's condition has improved or deteriorated.

For example, a description such as "Intake, 250 mL of water" is more accurate than recording "patient drank water adequately."

Lastly, use abbreviations cautiously to minimize confusion.

For example, avoid using the acronym IU for the international unit because it can be easily misinterpreted as the letters "IV" or the number "10". Use "International Unit" instead.