The Board of Registered Nursing will decide the penalty attached to such violation, which may include probation, license suspension or revocation. The Medical Record as Evidence Documentation in the nursing record is the only reliable means of proving that nursing assessment and intervention was performed in a timely and appropriate manner. Nursing care and the documentation of that care cannot be separated. They are two equally important parts of the same activity. Accuracy Never falsify a record.
Falsification destroys the credibility of the medical record and casts doubt on all other entries.
Sign entries immediately following the last word of entry. Charting care before it is given is dangerous. If circumstances prevent actually providing that care, the record has been falsified. Date and time entries should be timed as accurately as possible. Minutes may be critical in determining whether the nurse met the standard of care for timely intervention.