- Be Concise and Clear: While detail is important, being concise helps save time and ensures that the most critical information is highlighted. - Use Objective Language: Avoid subjective descriptions and focus on factual, observable information. - Follow a Logical Sequence: Document events in the order they occurred to provide a clear and coherent narrative. - Include Relevant Information: Ensure that all pertinent details are included, such as patient responses and follow-up actions.
