This lesson provides caregivers with a review of the basic principles of client care documentation, including the ethics and legalities involved in documentation. Discusses the DOs and DON’Ts of documenting client care in a variety of healthcare settings. Emphasizes the importance of accuracy, attention to detail, and timeliness.
- Name at least three purposes of clinical documentation.
- Describe the difference between objective and subjective observations.
- Discuss the five rules of clinical documentation.
- Describe the purpose of an incident report.
- Complete documentation according to the guidelines presented in this inservice and the policies of your workplace.