Stick to the facts—because facts speak for themselves. (No one can argue with the facts, but they can argue with your opinions!)
Remain brief and to the point. You don’t need to write a “book” about your clients!
Be specific! For example, it’s not very helpful to write “client ate well”. Writing something like “client ate 75% of lunch tray” is much better.
Avoid documenting the same information about a client day after day. Observe each client carefully and document even small changes.
If you document directly in your clients’ charts, make sure you have the right one before you begin to write!
Include each client’s full name in your documentation since there may be two clients with the same last name.
If you document a change in a client’s condition, be sure to write what you did about it. For example, if you document “Mr. Johnson gained 4 pounds since yesterday” , you should also document that you notified your supervisor. You might write “Called Jane Doe, RN about weight gain. She said she will talk to doctor.