Table 3

Basic do’s and don’ts in clinical record entries

DoDo not
Use timed entriesUse abbreviations
Make objective commentsMake offensive, humorous or personal comments
Document any noncomplianceUse ambiguous terms
Document oral communications (phone calls, in person conversations etc) and actions takenDelete or alter the contents of clinical notes in a way that is untrackable
Document informed consent
State objections regarding care or case management