Editing Fundamentals of Nursing (section)

== Documentation and communication ==

Document objectively, accurately, completely, and promptly. Chart what was observed and done, not conclusions or opinions about the patient. Never chart in advance. Correct an error by drawing a single line through it, writing the correction with your initials and the date, and never obliterating the original entry. Late entries are labeled as such.

Use SBAR (situation, background, assessment, recommendation) for handoff and for provider notification. A structured handoff at change of shift and at transfer reduces error, and the receiving nurse should have an opportunity to ask questions.

Report immediately to the provider or the charge nurse: a significant change from baseline, new or worsening pain, a fall, a medication error, unexpected bleeding, oxygen saturation below the ordered parameter, new confusion, chest pain, and urine output below the ordered minimum.