Legal Guidelines for Recording Flashcards by Micaela House | Brainscape

Q

Correct

A

Correct all errors promptly, using the correct method.

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Q

Record

A

Record all facts; do not enter personal opinions

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Q

Record

A

If an order was questioned, record that clarification was sought

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Q

Chart

A

Chart only for yourself, not for others

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Q

Keep

A

Keep your computer password secure

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Q

Avoid

A

avoid generalizations

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Q

Paper Charting

A

Begin each entry with the date/time and end with your signature and title.

Do not leave blank spaces in nurses’ notes

Write legibly in permanent black/blue ink.

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