Nursing documentation: principles, formats and legal value
- Safe practice
If it is not recorded, it is not on record: nursing notes tell, in order and truthfully, the patient's condition and the care given.
What it is
Nursing records are part of the clinical record. They describe in chronological order the patient's situation, progress and the nursing interventions given (Colombia's Law 911 of 2004, art. 35). The clinical record is a private, mandatory and confidential document (Resolution 1995 of 1999, art. 1). Every professional, technician or auxiliary who cares for the patient must record what they observe, decide and do (art. 4). A good record is truthful, timely, objective, legible and complete; it supports continuity of care, team communication and quality, and serves as evidence in a legal or ethics proceeding.
What it requires
- Record in real time, never before doing the intervention.
- Describe objective facts that another person could check.
- Record the patient's response to each intervention too.
- Protect confidentiality: only the patient, the team caring for them and those the law allows have access (Law 911, art. 36).
- In electronic records, each entry is tied to its author, with date and time, and cannot be changed once saved (Resolution 1995 of 1999, art. 18).
Components
- Narrative: chronological text that tells what happened.
- Electronic health record: a real-time, secure record for authorised users; each entry carries date, time and signature.
- SOAPIE: Subjective, Objective, Assessment, Plan, Intervention and Evaluation.
- Focus charting (DAR): Data, Action, Response.
- Charting by exception: a list of normal findings is agreed, and only abnormal findings are recorded.
How it is applied (and why)
- Identify the patient and the right record before writing — this avoids charting in someone else's record.
- Record during or right after care, never before — the record must reflect what really happened.
- Note the date and time of every entry — this lets anyone rebuild the sequence of care.
- Describe objective data and the patient's response, not opinions — the record must stand up to any review.
- Use only approved abbreviations and legible writing — this avoids misreading.
- Leave no blank spaces and never erase; correct right after, with a note — this keeps the document intact.
- Sign with your full name and professional registration — this identifies who is responsible for each entry.
- Keep the record confidential and log out of the system — this protects the patient's privacy.
Example of a focus (DAR) note, made-up data
| Part | Content |
|---|---|
| Focus | Surgical wound pain |
| Data | Reports pain of 7 out of 10; guards the abdomen when moving |
| Action | Prescribed analgesic given; repositioned with a pillow |
| Response | After 45 minutes reports pain of 3 out of 10 and sits up alone |
In nursing practice
- The nursing record is the shift's memory: whoever comes next only knows what was written down or handed over.
- In an ethics or court proceeding, the record is the main evidence of what was done.
- Each institution adopts its own forms; the professional requires or adopts those that meet the information needs (Law 911, art. 37).
Common mistakes
- Charting in advance something not yet done.
- Using correction fluid, crossing out or tearing out pages.
- Writing judgments («rude patient») instead of facts.
- Leaving blank space at the end of the note.
- Using the unit's own abbreviations that others do not understand.
- Sharing a system password or leaving the session open: only authorised users may access the record.
Test yourself
Think of the answer, then tap the question to see it.
Under Colombia's Law 911 of 2004, how is an error in a nursing record corrected?
Right after the text that needs it, with the corresponding note and keeping the sequence, without crossing out or altering (art. 38).
What must every nursing entry include?
Date and time, full name, signature and professional registration of the person responsible (Law 911 of 2004, art. 38).
What does the «timeliness» characteristic of the clinical record mean?
Recording care at the same time as it happens or immediately after (Resolution 1995 of 1999, art. 3).
What do the letters of DAR focus charting stand for?
Data, Action and Response, organised around one focus or patient problem.
Elsewhere in DurgiPedia
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Ley 911 de 2004, responsabilidad deontológica para el ejercicio de la enfermería (arts. 35 a 38) (Secretaría General del Senado de la República, 2004); Resolución 1995 de 1999, por la cual se establecen normas para el manejo de la historia clínica (Ministerio de Salud de Colombia, 1999); Nursing Fundamentals (Open RN), 2.5 Documentation (Open RN, Chippewa Valley Technical College (LibreTexts), 2022).
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Representative model, for educational purposes only.