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Documenting Correctly

By Heather Brown
December 04, 2014

Properly documenting information is essential. Improper documentation can do more harm than good if a lawsuit arises. It is a primary part of every employee to understand the importance of proper documentation and to document. Documenting should be completed immediately and not passed on to someone else to complete.

The key to good documentation is to document only the facts and the exact quotes made by the resident or employee. DO NOT document your personal opinion or criticisms about other workers or medical professionals.

1. Use dark blue or black ink ONLY. .

2. Make sure you have the correct resident chart. .

3. Document what you see, hear, smell and feel. .

4. Always date and initial your entry. .

5. Complete every question. Use N/A if it does not apply. .

6. Quote exactly what the resident or others involved said. .

7. DO NOT use personal opinions or subjective statements. .

8. Stick to the FACTS only. 9. Record the residents response. .

10. Ask the resident when the symptoms began. .

11. Describe the care provided. .

12. Assess using the facility assessment forms. .

13. Use present or past tense verbs in description, such as I observed or the resident stated .

14. Document resolution if it applies. .

15. Be sure the document is placed in the correct residents chart or file. .

16. If documenting late, note with the entry. .

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