Never use a pencil or correction fluid to change the writings. Do not correct medications and dosages "rehearsing" with the pen, to correct and avoid hiding place too, with markers or other. To err is human, to cover up a mistake is criminal. Just pull one or two lines above the part to be deleted, so that the error is still readable. Also applies to existing treatment. If the changes are minimal, one draw a line above the previous one, so that it is still readable after the fact, then write the new prescription in the spaces below.
Record the data in a clear, legible, which admits of no doubt, avoiding handwriting style "doctor's prescription."
Each sheet, especially if part of a multi-user must bear full name and serial number, in order
to return home quickly after the passage of operators "messy".
Each nurse must complete the folder itself and never on behalf of others, taking responsibility for your own records.
The problems identified are described in his diary nursing timely, accurate and essential, avoid forgetting information, noting accurately the user's symptoms and feelings, actions and possible outcome.
For reference later, if the diary is updated several times during the same turn, the date should be marked only on the first note, while the time is updated on all the notes below.
Sensations and symptoms should not be interpreted, but transcribed in "quotation marks" to indicate that the words quoted by the user. Should never be confused with the observations of ' nurses .
The unexpected behavior of a user, such as refusal to take a drug or perform a diagnostic test, it should be noted on the nursing diary, highlighting the reasons.
Abbreviations and symbols are used only if they are known to all members of the team. In places where they make extensive use, provide a legend available separately. Avoid "coined" abbreviations and acronyms of fantasy: the notations should be understandable to all operators.
Use technical terminology, correct and verified. Never irony in his diary: maintain a proper professional detachment, even describing events that can enhance the hilarity.