What are the Principles of Effective Documentation?
Effective documentation should adhere to the following principles:
Accuracy: Ensure that all information recorded is correct and free from errors. Completeness: Document all relevant patient information and nursing actions comprehensively. Timeliness: Record information as soon as possible after the event to ensure accuracy and reliability. Objectivity: Describe observations and facts without personal opinions or judgments. Legibility: Ensure that handwritten notes are clear and readable, or opt for digital records where possible. Confidentiality: Protect patient privacy by keeping documentation secure and sharing information only with authorized personnel.
