Documentation is any written or electronically generated information about a client that describes the care or service provided to that client . Health records may be paper documents or electronic documents such as , electronic medical records, faxes, emails, audios, or video tapes and images.
Outline
- Overview of documentation
- Principles of documentation
- Forms of documentation
- Characteristics of documentation
- Common record keeping forms
- Methods of nursing documentation
- Importance and benefits of documentation
- Don’ts of documentation
- Malpractices in documentation
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