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Nur 221 Nursing Documentation Guidelines Template
- Course
- NURSING 221
- Institution
- Gaston College
This is a comprehensive and detailed template on Nursing documentation guidelines. *Essential Study Material!!
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NURSING DOCUMENTATION GUIDELINESJoint Commission Official “Do Not Use” List
Do Not Use Potential Problem Use Instead
U (unit) Mistaken for “0”, “4”, or “cc” Write “unit”
IU (international Unit) Mistaken for IV or the number 10 Write “International Unit”
Q.D., QD, q.d., qd, Q.O.D., Mistaken for each other Write “daily”
QOD, q.o.d., qod Period after Q mistaken for “I” and “O” Write “every other day”
mistaken for “I”
Trailing zero (X.0 mg) Decimal point is missed Write X mg
Lack of leading zero (.X mg) Write 0.x mg
MS Can mean morphine sulfate for Write “morphine sulfate”
magnesium sulfate
MSO4 and MgSO4 Confused for one another Write “magnesium sulfate”
Do Not Use Potential Problem Use Instead
> (greater than) Misinterpreted as the number Write “greater than”
< (less than) “7” (seven) or the letter “L” Write “less than”
Confused for one another
Abbreviations for drug names Misinterpreted due to similar Write drug names in full
abbreviations for multiple drugs
Apothecary units Unfamiliar to many practitioners Use metric units
Confused with metric units
@ Mistaken for the number “2” two Write “at”
cc Mistaken for U (units) when Write “mL” or “ml” or “mililiters”
poorly written (“mL” is prefered)
μg Mistaken for mg (miligrams) resulting in Write “mcg” or “micrograms”
one thousand-fold overdose
Charting Do’s and Don’ts
• Verify information given by other HCP’s in chart • NEVER change anyone else’s charting, even if you know it
• Chart interventions and follow up to be inaccurate. Alert the person and have them correct it.
• Chart communication with other HCP’s • NEVER assume or draw your own conclusions, just chart
what you see/observe
• NEVER chart in advance
- “Rhythmic twitching” versus “seizures”
• NEVER chart for someone else or under someone
else’s name - “Patient fell” versus “ “walked into room, observed
patient on the floor”
• Chart everything
• Review your charting before you clock out *Review institutional guidelines regarding charting Source: jointcomission.org
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