Tips for good record keeping

1. Write legibly
Take a small extra time and care to write legibly in paper records. While you may be able to read your own hand writing, can anyone else?
2. Include the date and time
Dated and timed hand-written notices will be important if a claim arises several years later. Such information will explain the series of events during your procedure of the patient, even though you may not be able to keep in mind obviously what happened. With digital records, the time and date will be instantly recorded.Tips for good record keeping