Alabama Administrative Code
Title 610 - ALABAMA BOARD OF NURSING
Chapter 610-X-6 - STANDARDS OF NURSING PRACTICE
Section 610-X-6-.06 - Standards For Documentation
Universal Citation: AL Admin Code R 610-X-6-.06
Current through Register Vol. 43, No. 02, November 27, 2024
(1) The standards for documentation of nursing care provided to patients by licensed nurses are based on principles of documentation, regardless of the documentation format.
(2) Documentation of nursing care shall be:
(a) Legible.
(b) Accurate.
(c) Complete. Complete documentation includes
reporting and documenting on appropriate records a patient's status, including
signs and symptoms, responses, treatments, medications, other nursing care
rendered, communication of pertinent information to other health team members,
and unusual occurrences involving the patient. A signature of the writer,
whether electronic or written, is required in order for the documentation to be
considered complete.
(d) Timely.
1. Charted at the time or after the care, to
include medications. Charting prior to care being provided, including
medications, violates principles of documentation.
2. Documentation of patient care that is not
in the sequence of the time the care was provided shall be recorded as a "late
entry," including a date and time the late entry was made, as well as the date
and time the care was provided.
(e) A mistaken entry in the record by a
licensed nurse shall be corrected by a method that does not obliterate,
white-out, or destroy the entry.
(f) Corrections to a record by a licensed
nurse shall include the name or initials of the individual making the
correction.
Author: Alabama Board of Nursing
Statutory Authority: Code of Ala. 1975, §§ 34-21-1(3)(a), 34-21-1(3)(b), 34-21-2(c)(21).
Disclaimer: These regulations may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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