What are the Best Practices for Clear Documentation?
To ensure clear and effective documentation, nurses should:
Take Time: Allocate sufficient time for accurate documentation. Use Legible Handwriting: If handwritten notes are necessary, ensure they are legible. Be Specific: Use specific and unambiguous language. Avoid Abbreviations: Minimize the use of non-standard abbreviations. Review and Edit: Regularly review and edit notes for clarity and accuracy.
