What is the appropriate way to document patient care?

The appropriate way to document patient care involves using objective observations and completing documentation promptly. Objective observations refer to measurable and observable data, such as vital signs, physical findings, and clear factual statements that contribute to an accurate medical record. This ensures that the information is reliable and can be used effectively by other healthcare team members.

Completing documentation promptly is also crucial. Timely documentation helps to ensure that the care provided is accurately reflected in the patient's records while still fresh in the caregiver's mind. This reduces the risk of errors and ensures continuity of care, as other providers will have access to the most up-to-date information about the patient's condition and treatment plan. Making prompt, objective notes fosters better communication within the healthcare team and supports high-quality patient care.