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Principles of Documentation
· Be specific and definite in using words or phrases that convey the meaning you wish expressed
· Words that have ambiguous meanings and slang should not be used in charting
· Chart objective facts, not your interpretations or opinions
✓ Ate 50% of the food served.
X Ate with poor appetite.
✓ Refused medications.
✓ Seen crying.
✓ = correct
X = Wrong
Place the complaint of the client in quotation marks to indicate that it is his statement.
Date and Time
Document the date and time of each recording.
It is essential for accuracy in recording.
Record only information that pertains to the client’s health problems and care.
Accurate complete documentation will give legal protection to the nurse other health care professional of the institution and the client.
Client’s name and identification data must be written on each page of the clients records and entries must be accurate.
Document all information necessary to explain the events in a shift. Anyone reading the document should have a clear picture of what took place.
Only standard medical and nursing terminology and community recognized abbreviations and symbols should be used.
Recording of information on the clients must follow a chronological order charting statements must be logically organized according to time and content.
Blank spaces are not to be left on the chart and avoid writing outside the lines of the charting format.
Information within the chart is often of a personal matter as well as legal evidence of the care provided and should be available for the necessary health team members only.
Use proper grammar.
· Affix signature, place at the end of charting at the right hand margin of the nurses notes.
· Sign each entry with your full name and status, e.g. SN for Student Nurse, RN for registered nurse.
All due Medicines are given to Mr.Govind at 8pm by G.Stella
(Mrs.G.STELLA,RN) Registered Nurse
Bed bath given to Mrs. Sivagami at 6 am by R.Grace
( MISS.R.GRACE,SN) Student Nurse
· In case of error.
§ Correct errors by drawing a single horizontal line through the error
§ Write the word error above the line, then sign your signature
§ No ink eradication, erasers or use of occlusive materials
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