Here are some tips regarding documentation to keep in mind for the exam and for real life practice:
- Chart as soon as possible, especially vital signs. When the health care team rounds in the morning they need to know the most recent vital signs. Charting the at 10 am is not as useful
- Be as descriptive as possible. When describing an assessment finding don't hesitate to use non-conventional words if nothing else seems appropriate
- When charting about complex wounds it is very helpful to have a picture or tracing of the wound to monitor progression
- Remember to never use an eraser or liquid eraser on charts. Instead put a single line through the words and initial them
- Sign off on your medications after you administered them, so there is no confusion about what the patient did and did not receive
- Remember to use objective non-biased language
