Accuracy in documentation can be ensured by following these practices:
Timeliness: Document care as soon as possible after it is provided to ensure details are fresh in memory. Objectivity: Use clear, factual, and non-judgmental language. Specificity: Include specific details such as times, dosages, and patient remarks. Legibility: Ensure handwriting is readable or use electronic health records (EHR). Consistency: Follow institutional guidelines and standardized formats.
