To ensure proper documentation, nurses should follow these best practices:
Be Timely: Document care as soon as possible after it is provided to ensure accuracy and completeness. Be Objective: Record facts and avoid subjective opinions. Use clear, concise language. Use Standard Terminology: Employ standardized medical terminology to ensure clarity and consistency. Double-Check Entries: Review documentation for errors or omissions before finalizing entries. Follow Institutional Policies: Adhere to the documentation policies and guidelines established by your healthcare facility.
