5 documentation mistakes that put nurses at risk

5 documentation mistakes that put nurses at risk

🔴 It happens every day.
🟢 And it’s preventable.

Here are the 5 most common documentation mistakes I see as a coach and former quality care manager:

❌ Vague phrases like “patient seems fine”
✅ Say what you observed — vitals, behavior, facts

❌ Leaving out the patient’s response
✅ Always document what happened after you acted

❌ Copying and pasting without updating
✅ Update every section — or say, “unchanged since…”

❌ No time stamps
✅ Time = proof. Without it, your care has no timeline

❌ Not documenting calls, escalations, or instructions
✅ If it’s not in the chart, it didn’t happen

These mistakes don’t mean you’re careless.
They mean you were never given the right tools.

That’s why I built nytngale

To give nurses, managers, and clinics the clarity, structure, and confidence they deserve.

If documentation has ever made you second-guess yourself,
This cheat sheet will help.

✅ Simple.
✅ Practical.
✅ Built to protect you.