Accurate documentation requires attention to detail and adherence to certain principles:
- Timeliness: Record observations as soon as possible to ensure accuracy. - Objectivity: Focus on factual information rather than subjective opinions. For example, instead of writing "patient seemed anxious," document "patient exhibited fidgeting and rapid speech." - Clarity: Use clear and concise language. Avoid jargon and abbreviations that may be misunderstood. - Completeness: Ensure all relevant information is included. Omitting details can compromise patient care. - Legibility: If documenting by hand, ensure handwriting is readable. Electronic records should be free of typographical errors.
