Basic Rules for Charting!

12.

All charting is done in black or blue ink with a ballpoint pen. Do not use felt-tipped pens

13.

Always record date and time. Include month , day, and year. Some facilities document charts using military time (24 hour clock). Time may be indicated by using conventional 12 hour notation of by using the 24-hour clock.

2.

Do not skip lines.

9.

If facility's policy allows,read notations by other personnel

7.

Indicate number of times an event occurs during a shift,day,week,etc

8.

Make follow-up notations of results of actions relative to the care plan

11.

Never chart a procedure before it has been performed.

4.

Never erase. If you make a mistake, draw a line through the entry and wrote "mistaken entry". Write your initials by it for identification. Use a black or blue ballpoint pen.

10.

Record resident's reactions to family and visitors.

1.

Report and record in an objective way.

6.

Use direct quotes when describing an emotional statement

3.

Use only approved abbreviations (see facility's policy)

5.

Use simple, correct terminology. Use correct grammar, punctuation, and spelling