Basic Rules for Documentation

Provide Correct Information, Avoid Generalized Phrases, Be Objective, Be Timely, Specific, Accurate and Complete, Chart AFTER the care is provided, Chart ordered care as given or explain deviation, Chart ASAP, Chart facts only, Chart only care you have given, Chart only as observed without opinions or speculation, Fill all spaces, follow institution policy, correct grammar and punctuation is key, correct any errors per institution policy, if order is questioned seek clarification, note patient response to treatment, Sign charting per institution policy, use quotes as appropriate, Use only abbreviation approved by facility, black non-erasable ink only, note any late entries as late before proceeding with notations, write legibly