Record keeping and good documentation
Pages 4

It is also important to remember anything you record will be open to a wider audience, so ensure your entry is clear and unambiguous and conveys the information you want it to.

Box 9: Ten tips for good record keeping

1. Remember, your entry will be read by a wider audience, so it needs to:

the reader to important sections. 2. Write your entry so that someone reading it can understand

what you mean and act upon any instructions for clinicians on the next shift/next day, etc.