Legal aspects of nursing documentation for the Alzheimer's patient

1. Bergerson (1988) developed a set of charting rules called the FACT system (charting that is Factual, Accurate, Complete, and Timely). Nurses' notes are viewed as legal sources of documentation. 2. Nurse's notes made regarding the patient's cognitive status, ability to communicate and participate in treatment decisions, and safety needs may be carefully reviewed by the court system for a variety of reasons. 3. Nurses caring for patients with Alzheimer's disease must recognize that the primary function of any charting or documentation is optimal care for the individual patient. Nurses should not chart in anticipation of a legal review of the charting. However, nurses also must be aware that a legal challenge may prompt a review of the record and require the nurse to explain or clarify entries that have been made.