Sign each entry. Correct errors properly. Add the correct information and an explanation on the next available line , and initial the changes. Never erase or scribble over an erroneous entry, which could appear like an improper cover-up if you were ever involved in a lawsuit. A job well done What you write in a patient's chart tells others about the nursing care you give.
Proper documentation creates a lasting impression of a job well done.
Your patient asks to see the chart. Hospitals own hospital records and physicians own their office records. Yet many courts have granted patients the right to learn the details of their medical treatment. After you get permission to show the patient the chart, stay with him while he reads it. Help interpret abbreviations and jargon and explain that changing anything would be illegal.