Nursing Documentation 101: Documentation Principles page 1
Documentation Principles 1. Document in the correct client chart or record. 2. Write neatly, legibly and in ink. 3. Use correct spelling and grammar. 4. Document in chronological order and promptly. 5. Correct errors or late entries as per standards. 6. Sign correctly your name and designation. 7. Identify by name other individuals contacted. 8. Maintain client confidentiality. 9. Use “Not-Applicable” or “NA” in blank spaces. 10. Document medication omissions and refusals. 11. Document only care you provide and never ahead of time. 12. Do NOT document complaints from staff, poor care or accusations.
PRINCIPLES