Writing a defensible nursing note
Record observable facts, measured values and the person's own words. Write at the time, not at the end of the shift. Sign every entry. Include: what was assessed, what was done, how the person responded, who was notified and at what time. Avoid interpretation, blame and vague adjectives. Write "refused the morning dose, said I do not want it today" rather than "uncooperative". Never chart in advance. Never erase: correct visibly, dated and initialled.