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Record the facts legibly, in ink
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Never erase, scratch out, or apply correction fluid. Cross through an error once, date and initial the change.
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Do not leave blank spaces in your nursing notes.
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Never chart for another person.
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Avoid interpreting patient statements. Record exactly what the patient said in quotation marks.
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Correct all errors in a timely manner.
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Chart in a timely manner.
Computerized Charting
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Never lend access ID to another person
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Maintain confidentiality of documented information printed from the computer