Maintaining accurate and complete records is an important part of operating an Assisted Living Community. Good documentation can help to ensure consistent quality care for your residents, and help to protect your liability. When reviewing your documentation practices, keep these basics in mind:
- Accurate and Objective
Documentation should always be accurate and objective. Document only the things you see, hear, or touch. Never, for example, document something was done if you didn’t in fact do it yourself or witness first hand.
- Date and Time
Every record, form, narrative entry, and piece of documentation should be dated, and the time should also be recorded with narrative entries. Be clear when documenting times. In some care settings “military time” may be used for better clarity, e.g., 1300 instead of 1:00 pm. Clarify the policy in your Community
- Do Not Assign Blame
Avoid assigning blame or calling attention to errors. Staff disputes regarding resident care may occur and may be valid, but they do not belong in the resident’s record
It is best to avoid abbreviations, but if you allow them in your Community only use standard and setting-approved abbreviations.
- No Blank Spaces
Do not leave any blank spaced on a form or in a record. Blank spaces could be filled out by someone else at a later time, allowing your entry to be modified. Always line out blank spaces or list “n/a” as appropriate.
- Write Legibly
Your documentation doesn’t help anyone if you are the only person who can read it. Although we sometimes find ourselves in a hurry at work, take time to write neatly and clearly.
Always write in blue or black ink. This prevents the possibility of a record being modified at a later date, and if it is ever necessary to photocopy or fax a document blue or black ink will reproduce clearly.
- Do Not Document Care by Someone Else
Unless stated otherwise, anyone reading your documentation assumes that you performed the care being described. If, for example, another caregiver assisted a resident with their morning shower, that caregiver should be the one to note it in the record.
- Correct Errors
It’s ok if you make a mistake in a record. What’s not ok is to use the wrong technique when correcting your error.
NEVER: Use white out, completely obscure an error with a pen or marker, destroy a document and attempt to recreate it, or erase an entry. If you make a mistake, simply line it out with a single straight line, write the word “error” and initial the entry. Then go to the next blank line and start a new entry.
Last, but certainly not least, always sign your entries, forms, and documents. Be sure to include your credentials, if applicable, such as “RN.”