Documentation Principles in Health Care
Record keeping and documentation practices should be followed to ensure the patientunit health records (UHR) is up to date and maintained according to laws and acceptableprofessional practices and principles. Health records should be complete, timely and concise.The entries should address documentation requirements and be specific, timely, accurate,concise clear and legible. All inpatient documents should be completed within fourteen daysafter discharge of a patient. The entries […]