Records should be meaningful, clear accounts of the patients' care

Handwriting should be legible

All entries should be signed. In the case of written records the

person's name and job title should be printed alongside the first entry.

You should put the date and time on all records. This should be in real

time and chronological order and be as close to the actual time as

possible.

Records should be accurate and recorded in such a way that the

meaning is clear.

Records should be factual, not include unnecessary abbreviations,

jargon, meaningless phrases or irrelevant speculation

You should use your professional judgement to decide what is

relevant and what should be recorded.