1. (1) The standards for documentation of care provided to patients by the NST-C are based on principles of documentation, regardless of the documentation format.

2. (2) Documentation of supportive nursing services shall be:

   1. (a) Legible.
   2. (b) Accurate.

   3. (c) Complete. Complete documentation includes reporting and documenting on appropriate patient record a patient's status, including signs and symptoms observed if indicated, responses, assistance provided, bedside testing results, vital signs, NST-C supportive care provided, communication of pertinent information or changes in patient status to other health team members and the nurse supervisor, and any unusual occurrences involving the patient.

      1. 1. A signature of the writer, whether electronic or written, is required in order for the documentation to be considered complete. The NST-C shall sign records with the designation NST-C on the patient record.
   4. (d) Timely.

3. 1. Charted at the time or after the care is delivered. Charting prior to care being provided, including supportive nursing service skills, violates principles of documentation.

   1. (e) A mistaken entry in the record by an NST-C shall be corrected by a method that does not obliterate, white-out, or destroy the entry.
   2. (f) Corrections to a record by an NST-C shall include the name or initials of the individual making the correction.

Author: Alabama Board of Nursing

Statutory Authority: Code of Ala. 1975, §34-21-2, Alabama Act No. 2024-249.

History: New Rule: Published July 31, 2024; effective September 14, 2024, operative October 1, 2024.