Why Documentation Matters
The patient care report is a medical record, a legal document, and a source of quality data. If it was not written down, it did not happen. Accuracy and completeness protect both patient and provider.
Writing Well
Use objective language, such as what you saw, heard, and measured, rather than opinions. Use quotes for what the patient says. Avoid unapproved abbreviations and never alter a record after submission without proper correction procedures.
Key Elements
Include times, vital signs, assessment findings, treatments, patient response, and transfer of care. Document pertinent negatives, such as no history of trauma. Keep patient information confidential under HIPAA.