Question

Denise, a nursing student, has been trying to improve her documenting skills. Which skills should she focus on in her training? Select all that apply.

writing factual, clear, and accurate information legibly

writing the documentation as close to the time of care as possible

dating additional information

writing all information in emphatic order or order of importance

using approved abbreviations and symbols

using notebook paper to record information

Answer 1

Correct selections:
- writing factual, clear, and accurate information legibly
- writing the documentation as close to the time of care as possible
- dating additional information
- using approved abbreviations and symbols

Brief rationale:
- Documentation must be factual, clear, accurate, and legible to ensure safe, legal communication.
- Chart as soon after care as possible to ensure accuracy and timeliness.
- Additional entries should be dated (and timed) so the record is complete and chronological.
- Only use approved abbreviations/symbols to avoid misinterpretation.

Not appropriate:
- Writing information in order of importance (documentation should be chronological).
- Using notebook paper (use the official medical record or approved forms only).