Standardized formats and templates should be used to ensure consistency and comprehensiveness. Documentation should be:
Timely: Entries should be made as soon as possible after the care is provided to ensure accuracy. Factual and accurate: Information should be based on observed data and free from personal opinions. Complete: All relevant information should be documented, including any changes in the patient’s condition. Legible: Handwritten notes should be clear and readable if electronic health records are not used. Confidential: Patient information should be kept secure and only shared with authorized personnel.
