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Nursing Field Notes / Nursing Core · Med-Surg Course

Documentation & Handoff 📝

SBAR · what goes in the chart · the abbreviations that are banned

NG-403 Nursing Core ADHD-friendly visual edition

If it is not documented, it did not happen — and if it is documented wrongly, it is evidence against you. Chart what you observed and what you did, in that order, and never anything you did not see yourself.

SBARSituation · Background · Assessment · Recommendation
Never chartOpinion, blame, or that an incident report was filed
An errorOne line through it, initial and date. Never erase or white out.
Late entryLabel it “late entry” with both times

🧨 What starts it

A chart line with an error corrected the right way - one line through it, initials and date, the original still readable - beside the three wrong ways: scribbled out, correction fluid, erased.
Everything except the single line destroys the record, and afterwards it looks like concealment. Swipe it sideways if it is cut off, or tap to open it full size.
The rules that generate the questions
  • Chart after you act, never before. Documenting a medication before giving it is falsification.
  • Objective before subjective. Write what you measured and observed; put her words in quotation marks.
  • Only what you did or witnessed. Never chart for someone else.
  • Correct an error with a single line through it, then your initials and the date. The original must stay readable. No erasing, no correction fluid, no scribbling out.
  • Late entry is labeled as such, with the time of the event and the time of writing.
  • No blank lines. Draw a line through unused space so nothing can be added.
  • Sign every entry with name and credentials.
What never goes in the chart
  • Opinions, judgments or blame — “patient was uncooperative” is opinion; “patient declined the medication, stating ‘I don’t want it’” is fact.
  • That an incident report was completed. Chart the assessment and the notification, not the report.
  • Staffing complaints or criticism of colleagues.
  • Anything you did not personally do or see.
Banned abbreviations

These are on the official do-not-use list because they have killed people.

  • U → write unit. Mistaken for 0 or 4.
  • IU → international unit. Read as IV or 10.
  • QD, QOD → daily, every other day.
  • Trailing zero (1.0 mg) → write 1 mg. The decimal is missed.
  • Missing leading zero (.5 mg) → write 0.5 mg.
  • MS, MSO₄, MgSO₄ → write the drug name out.

🔎 What you will see

SBAR — the handoff format
  • S — Situation. Who, where, and what is happening right now. One or two sentences. “This is Sarah on 4 East. Mrs Doyle in bed 12 is short of breath.”
  • B — Background. The relevant history only. Admitting diagnosis, day post-operative, code status, allergies.
  • A — Assessment. Your vital signs and findings, and what you think is going on.
  • R — Recommendation. What you want. “I need you to see her now,” or “can I have an order for a chest x-ray?”

The R is the part people leave out and it is the part that gets action. State what you want to happen.

Bedside handoff
  • Done at the bedside with the patient, so she can correct and add.
  • Both nurses look at drips, drains, dressings, pumps and the IV site together.
  • Cover code status, allergies, isolation, fall and pressure-injury risk, and anything outstanding.
  • Sensitive information is discussed away from the bedside.
  • Use a standard tool so nothing is missed on a busy shift.
Verbal and telephone orders

Take them only in an emergency or when the provider cannot enter it. Write it down, then read it back, then get it confirmed — read-back is mandatory. Spell drug names that sound alike and repeat the dose digit by digit. The provider signs it within 24 hours.

🩺 What you do

Charting that holds up
  • Timely. As close to the event as possible.
  • Specific. “300 mL of bright red drainage”, not “moderate amount”.
  • Complete. Assessment, action, patient response, and who was notified with the time.
  • Teaching is documented with what was taught, how it was taught, who was present, and how she demonstrated understanding. “Patient taught” alone proves nothing.
  • Declined care is documented with her stated reason and who was notified.
Confidentiality
  • Access only the records of patients in your care. Curiosity is a HIPAA violation.
  • Never share a login or leave a workstation unlocked.
  • No patient information in a lift, a corridor, or on social media — including anything that could identify her.
  • Take care with the whiteboard, the bedside chart and the printer.
Documenting an event
  • Chart the assessment findings, the interventions, the patient’s response, and who was notified and when.
  • Do not chart that an incident report was filed.
  • Do not speculate about cause. “Found on the floor beside the bed” — not “fell out of bed” if nobody saw it.
  • Quote her explanation rather than paraphrasing it.

⚡ Quick recall

SBARSituation · Background · Assessment · Recommendation
Never chartOpinion, blame, or that an incident report was filed
An errorOne line through it, initial and date. Never erase or white out.
Late entryLabel it “late entry” with both times
What does SBAR stand for, and which part is most often missed?
Situation, Background, Assessment, Recommendation. The Recommendation is the one people leave out, and it is what gets action.
How do you correct a charting error?
One line through it, initial and date. The original must still be readable.
Should you chart that you completed an incident report?
No. Chart the assessment, the interventions and the notification only.
Why is "1.0 mg" wrong?
The trailing zero can be misread as 10 mg. Write 1 mg.
Nobody saw her fall. How do you chart it?
"Found on the floor beside the bed" — describe what you found, do not assume a fall.
What is required for a telephone order?
Write it, read it back, get it confirmed, and have it signed within 24 hours.