Nursing Diagnosis and the Nursing Process
Documentation Standards
Legal requirements for recording the nursing process to ensure continuity of care and professional accountability.
Key Principles
- SOAP format: Subjective, Objective, Assessment, Plan.
- Charting by Exception: Documenting only deviations from established norms.
- Accuracy: Ensure entries are timely, factual, and legible.
- Corrections: Never use white-out; draw a single line through errors and initial.
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