Basic Rules for Documentation

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Basic Rules for Documentations	All documents should have the correct patient name, identification number, date of birth, date, and time if appropriate.
Basic Rules for Documentation	Use only approved abbreviations and medical terms.
Basic Rules for Documentation	Be timely, specific, accurate, and complete
Basic Rules for Documentation	Write legibly (for written documentation)
Basic Rules for Documentation	Follow rules of grammar and punctuation.
Basic Rules for Documentation	Fill all spaces; leave no empty lines. Chart consecutively. Go line by line. Do not indent left margin.
Basic Rules for Documentation	Chart after care is provided, not before.
Basic Rules for Documentation	Chart as soon and as often as necessary.
Basic Rules for Documentation	Chart only your own care, observations, and teaching; never chart for anyone else.
Basic Rules for Documentation	Use direct quotes when appropriate.
Basic Rules for Documentation	Be objective in charting; only what you hear, see, feel, smell.
Basic Rules for Documentation	Describe each item as you see it: for example, "white metal ring with clear stone" (rather than "diamond ring"). Do not speculate, guess, or assume.
Basic Rules for Documentation	Chart facts; avoid judgmental terms and placing blame.
Basic Rules for Documentation	Document only what you observe, not opinions. Never use charting to accuse someone else.
Basic Rules for Documentation	Document only what you observe, not opinions. Never use charting to accuse someone else.
Basic Rules for Documentation	Sign each block of charting or entry as directed by the agency policy.
Basic Rules for Documentation	Sign each block of charting or entry as directed by the agency policy.
Basic Rules for Documentation	When a patient leaves a unit (e.g., to go to x-ray laboratory, or office), chart the time and the method of transportation of departure and return.
Basic Rules for Documentation	Chart all ordered care as given or explain the deviation (nothing by mouth [NPO] for laboratory, off unit, refused, etc).
Basic Rules for Documentation	Note patient response to treatments and response to analgesics or other special medications.
Basic Rules for Documentation	Use only hard-pointed, permanent black ink pens; no erasures or correcting fluids are allowed on charts for written patient records.
Basic Rules for Documentation	If a charting error is made, identify the error according to facility policy and make the correct entry.
Basic Rules for Documentation	When making a late entry, note it as a late entry and then proceed with your notation: for example, "Late entry ____________," or as dictated by the facility policy.
Basic Rules for Documentation	Follow each institution's policies and procedures for charting.
Basic Rules for Documentation	Avoid use of generalized empty phrases such as "status unchanged" or "had good day."

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	Creado por SherieChristina hace más de 9 años