What to Never Document
Specific things that hurt you legally.
Some chart entries create legal exposure. Avoid specifically.
Avoid
Blame language ('this would not have happened if...'). Opinions about other staff. Diagnoses (you're not the provider). Speculation. Disparaging comments about patient or family.
Replace with
Factual observations. Direct quotes. Objective measurements.
Quick check
Loading a question…
How ready are you right now?
10 real NCLEX questions, free, in your browser. See how close you are to ready and which subjects are costing you.
Try 10 questions free