Effective documentation involves several key practices:
Accuracy: Ensure that all information is factual and precise. Timeliness: Document as soon as possible after the care is provided. Thoroughness: Include all necessary details to provide a complete picture of the patient's care. Objectivity: Record observations objectively without personal bias or interpretations. Legibility: Ensure that handwritten notes are readable, or use electronic health records (EHR) for clarity.
