Documentation & SBAR

Why documentation is a clinical skill

The chart is a legal record, a communication tool, and the basis of funding and quality review. In a complaint or lawsuit, the standard applied is simple: if it is not documented, it did not happen. Your memory of good care is not evidence of it.

But the more common daily consequence is smaller and worse — the next nurse doesn't know something, and the patient pays for it.

What good charting looks like

Factual. What you observed and measured, not what you concluded.

Not: "Client appears anxious." Better: "Client pacing in room, respiratory rate 24, states 'I can't stop worrying about the surgery.'"

Objective before subjective. Quote the patient rather than paraphrasing their emotional state.

Timely. Chart as close to the event as possible. Late entries are labelled as late entries with the actual time of the event and the time of writing.

Complete. Assessment, intervention, response. Charting that you gave something without charting what happened next is half a record.

Never do these

• Chart in advance. Ever. Charting a medication before giving it is falsification.
• Chart for someone else, or let someone chart for you
• Erase, white out, or delete. Draw a single line through an error, initial it, and write the correction
• Use vague filler: "slept well", "tolerated well", "no complaints"
• Blame or comment on colleagues in the chart
• Reference the incident report in the health record

SBAR

The handoff format that gets a doctor to act at 3am.

S — Situation. Who you are, who the patient is, and the problem in one line.

"This is Chanpreet, RN on 4 West. I'm calling about Mr. Sharma in 412, who has a respiratory rate of 28."

B — Background. The relevant history only.

"He's post-op day two from a bowel resection, no cardiac history."

A — Assessment. What you think is going on. State it — you're allowed to.

"His rate has climbed from 18 over three hours, sats are 91 percent on room air, and he's more anxious. I'm concerned about a PE."

R — Recommendation. What you want. Be specific.

"I'd like you to come and see him now, and I'd like an order for oxygen and a chest x-ray."

The recommendation is the part people leave off, and it's the part that determines whether anything happens. "I just wanted to let you know" ends a call with nothing changed.

Before you call

Have the chart, the last set of vitals, the medication list, allergies, and a pen. Know what you want. Being asked a question you can't answer costs you the call's momentum and delays the patient's care.