What Are the Best Practices for Complete Documentation?
Nurses can employ several best practices to ensure thorough documentation: - Timeliness: Documenting information as soon as possible after an event occurs. - Accuracy: Ensuring all entries are accurate and based on factual information. - Clarity: Writing clearly and concisely to avoid misunderstandings. - Comprehensiveness: Including all relevant information, such as patient assessments, interventions, and responses. - Legibility: Ensuring handwriting is legible if using paper records, or using standardized abbreviations and terminology in EHRs.
