NCLEX RN GUIDE                                                                                   the best of NCLEX


 Legal Guidelines for Charting
  1. Record the facts legibly, in ink

  2. Never erase, scratch out, or apply correction fluid. Cross through an error once, date and initial the change.

  3. Do not leave blank spaces in your nursing notes.

  4. Never chart for another person.

  5. Avoid interpreting patient statements. Record exactly what the patient said in quotation marks.

  6. Correct all errors in a timely manner.

  7. Chart in a timely manner.

Computerized Charting

  1. Never lend access ID to another person

  2. Maintain confidentiality of documented information printed from the computer