Documentation

Why this matters

Documentation supports continuity of care. It helps the next person understand what happened, what changed and what still needs attention. Poor documentation creates risk and confusion.

Expectations

• Follow the facility documentation process.
• Record information clearly and promptly.
• Report incidents, changes or concerns through the correct channel.
• Ask if you are unsure where or how something should be documented.
• Keep notes factual, professional and relevant.

Common mistakes

• Leaving notes until the end of a busy shift.
• Writing vague or emotional comments.
• Failing to report an incident because it seemed minor.
• Assuming someone else will document the concern.

What great workers do

• Document as close to the event as possible.
• Use clear, factual language.
• Escalate concerns before they become bigger issues.
• Understand that good documentation is part of good care.