In a new agency, the policy requires documenting after each patient. The nurse used to chart at the end of shift and finds the new method more effective. How should she proceed?

• A. Follow agency policy
• B. Continue old practice
• C. Document after shift anyway
• D. Ask for a waiver

Answer: (A)

Following the agency’s documented process for when to record patient information is essential for patient safety, continuity of care, and legal accountability. Policies set standard timing to ensure notes are accurate and complete, capture details while they’re fresh, and provide a clear record for anyone who uses or reviews the chart later. If the nurse finds charting after each patient to be more effective, she should implement that approach within the policy framework—documenting right after each encounter, with accurate times and details, rather than delaying until the end of the shift. If anything about the policy seems impractical, the appropriate step is to discuss it with a supervisor or policy committee to seek clarification or a potential revision, not to disregard the policy.