The Importance of Proper Documentation in Nursing

It was 2:45 a.m. when everything changed. After a long night, I finally found a moment to sit down. One of my patients, a gentle elderly gentleman with dementia, had been experiencing restlessness and pain since midnight. I had administered his scheduled pain medication around 1:30 a.m., carefully documented it, and noted his appreciative response: “Thank you, dear. That helps.”

An hour later, his daughter unexpectedly arrived. As I entered the room, I overheard her saying, “You mean they haven’t given you anything for pain?”

The patient, clearly confused and fatigued, just nodded.

The daughter’s reaction was immediate and intense. She stormed to the nurses’ station, demanding to speak to the charge nurse. “My dad said nobody has given him any medication all night—what happened to his morphine? Who took it?”

In an instant, I found myself under scrutiny. A missing narcotic, a patient who couldn’t clearly communicate his experience, and it was my word against theirs.

I am grateful every day that I had documented the medication administration right away—time given, response observed, and a verified count with the Pyxis.

That documentation saved me.

That small, timestamped detail was the only thing that prevented a simple misunderstanding from escalating into a significant incident.

If It’s Not Documented, It Didn’t Happen

We often repeat this phrase, but its truth becomes painfully clear when we find ourselves trying to reconstruct events from memory.

In my situation, having precise documentation of the medication, the patient’s response, and the count protected me from a potential disaster. It reaffirmed that our charting is our defense.

Even in times of exhaustion, chaos, or stress, documentation must be prioritized. It’s not just about our protection; it’s about safeguarding our patients, our licenses, and the integrity of our practice.

Communicate Clearly: State It, Confirm It, Document It

Every interaction—especially those concerning medication, verbal orders, or patient concerns—requires clarity and confirmation.

Repeat the orders back. Clarify the patient's wants. If there’s any doubt about your care, document that too. An entry like “Patient expressed concern that pain medication was not effective” is valid and necessary.

You’re not merely covering yourself—you’re establishing a clear, consistent trail of communication that can serve as your advocate if necessary.

Maintain Objectivity in Your Notes

What saved me wasn’t just that I documented; it was how I documented. I avoided vague language and phrases like “seems like.” I included the patient’s exact words and the precise time of administration.

Let your chart reflect what you observed—not what you think or assume. That distinction can mean the difference between a defensible note and one that raises questions.

Don’t Hesitate to Escalate

If something feels off, speak up. If a family member is accusing you, involve your charge nurse. If a provider’s order seems questionable, clarify it. Trust your instincts.

And always write an incident report if you suspect the situation could become an issue later. This isn’t about being a whistleblower; it’s about protecting yourself and your practice.

Support Each Other

Nursing is a team effort. If you’re administering a narcotic, have a colleague double-check it with you. If you’re navigating a tough conversation with a family, invite your charge nurse to join.

Having one more set of eyes can make all the difference.

Final Reflections: This Could Happen to Any Nurse

That night, I did nothing wrong. However, without proper documentation—without noting that the patient had verbally responded—it could have been a very different situation.

We all entered this profession to help others. But part of that help involves protecting the care we provide through clear and consistent communication.

So, to my fellow nurses: Document as if your license depends on it—because sometimes, it truly does.

And remember, no matter how fast-paced your shift feels, you matter too. Your voice, your name, your reputation—they all deserve protection—every single time.

(Original by Lorie Brown, RN, MN, JD)