1. Double-Check Entries: Review documentation for errors before finalizing. 2. Use Standardized Terminology: Employ approved medical abbreviations and terminology to avoid misinterpretation. 3. Be Detailed and Specific: Avoid vague statements; be as detailed as possible. 4. Document as Soon as Possible: Record information immediately after care is provided to ensure timeliness. 5. Follow Institutional Policies: Adhere to the documentation protocols and standards set by the healthcare facility.
