*12 Principles of Nursing Documentation* 1) Accuracy in charting 2) Date and Time Document the date and time of each recording. 3) Correct Spelling It is essential for accuracy in recording. 4) Appropriateness Record only information that pertains to the client’s health problems and care. 5) Legal Protection Accurate complete documentation will give legal protection to the nurse other health care professional of the institution and the client. 6) Accuracy Client’s name and identification data must be written on each page of the clients records and entries must be accurate. 7) Completeness Document all information necessary to explain the events in a shift. Anyone reading the document should have a clear picture of what took place. 8) Brief Only standard medical and nursing terminology and community recognized abbreviations and symbols should be used. 9) Organizations Recording of information on the clients must follow a chronological order charting statements must be logically organized according to time and content. 10) Omissions Blank spaces are not to be left on the chart and avoid writing outside the lines of the charting format. 11) Confidentiality Information within the chart is often of a personal matter as well as legal evidence of the care provided and should be available for the necessary health team members only. 12) Standard Spell correctly Use proper grammar. Put signature.. #nursinglife #nurse #nursingstudent #nurselife #nurses #nursesofinstagram #nurses #instagood #instaeducation #education https://www.instagram.com/p/CoXgCaBL9Dw/?igshid=NGJjMDIxMWI=
