Nursing Documentation and Record Keeping
Accurate documentation is a legal and professional duty. Records must be clear, factual, timely, and confidential to support safe, continuous care.
Practice Nursing Documentation with PassMate AI →Key Points to Know
What you must know about Nursing Documentation
Documentation must be accurate, factual, complete, timely, and legible.
Record care as soon as possible after it is given — never in advance.
Do not erase or use correction fluid; draw a single line through an error, and sign it.
Every entry must be dated, timed, and signed by the nurse.
Records are legal documents — "if it was not documented, it was not done".
Maintain patient confidentiality at all times.
NMCN Exam Tips
How this topic appears in the NMCN exam
Never chart care before it is performed.
Correct errors with a single line and your signature — no correction fluid.
"Not documented = not done" is a classic legal principle.
Every entry is dated, timed, and signed.
Practice Question
Test yourself
A nurse makes an error while writing in a patient's chart. The correct way to correct it is to:
Explanation
To maintain the legal integrity of the record, an error is corrected by drawing a single line through it (so it remains legible), labelling it as an error, and signing/dating the correction. Correction fluid and erasing are never acceptable.
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