Why document?
Documentation of patient care and interventions are important for a number of reasons.
- To facilitate the continuum of patient care
- To allow evaluation of care provided
- For research or epidemiological needs
- To allow clinical unit management
- To meet statutory requirements
- In case the information is required for medico- legal defence
Your responsibilities
- Write in black pen only
- Ensure you are concise and accurate
- Never make derogatory comments
- Ensure your writing is legible
- Always time and date entries
- Sign entries and print name and designation (All entries must be co-signed by your supervisor)
- Do not time or date entries retrospectively
- Do not retrospectively amend
- Rule a single line through writing if an error is made. Sign and date this change. Do not use white out correction fluid (liquid paper)
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