Question

Documentation provides records of the patient’s needs, care provided, and clinical outcomes. Which are important documentation strategies to develop good documenting skills? Select all that apply.

Write factual, clear, and accurate information.

Write quickly and illegibly.

Write information in order of importance.

Date additional information.

Use approved abbreviation and symbols.

Use correct format on the approved forms.

Answer 1

Correct choices:
- Write factual, clear, and accurate information.
- Write information in order of importance.
- Date additional information.
- Use approved abbreviations and symbols.
- Use correct format on the approved forms.

Explanation: Documentation should be objective, clear, complete, timely (include dates/times), follow approved abbreviations and the facility’s forms/format, and be organized logically. “Write quickly and illegibly” is incorrect — entries must be legible.