Record only objective facts - what you see and hear. Avoid general terms and vague expressions. Jurors do not look kindly upon errors, particularly in a setting where people's lives are at stake. Be sure to sign and date both entries. Also, use a different color ink for the second entry, so that the correction shows clearly.
Jurors are skeptical of people's memories.
Chart your observations immediately, while they are still fresh in your mind. Document in ink, and write legibly. According to a number of court rulings, this is a requirement. Moreover, if the physician does not respond, the nurse must take the matter through the administrative hierarchy - all the way to the hospital administrator if necessary. Following these rules will help you provide good care to patients and prevent financial disaster for yourself.