Document only patient care that you have provided and physical findings you have observed firsthand. Although every healthcare professional has heard that rule repeatedly, far fewer have been alerted to this important exception: If you are told of an incident directly affecting the health and well-being of a patient—say, a fall or medication error—that would otherwise go unreported, you may have a duty to document it. But attempt to verify the details with a witness first.

If the person who witnessed the incident is a family member or other non-professional, or the patient is the one who reports it to you, the responsibility for the documentation belongs to you.

To avoid giving a misleading picture, however, it is essential to use language clearly indicating that what you are reporting is hearsay. For example: “Mary Harris (the patient’s mother) said the patient fell while getting out of bed.” If the witness is employed by your organization as a healthcare provider, he should be the one to do the charting. If that’s not possible because of a family emergency, perhaps, or other unanticipated circumstances, record the details of the incident yourself instead, clearly identifying the source of your information.