Professional Documents
Culture Documents
Source-Oriented (SO) Charting Is A
Source-Oriented (SO) Charting Is A
a. Restrict access
b. Ethical codes and legal responsibility – patient’s record is protected legally
c. Policies and procedures to ensure privacy and confidentiality
III. Identify and discuss guidelines for effective recording that meets legal and ethical standards.
Guidelines:
• Date and time should be according to the 24 hour military clock.
• Dark pen must be use (no sign-pen allowed)
• Concise
• Completeness
• In-order
• Legible
• Accurate
• Correct spelling
• Avoid writing the word error
• Follow agency policy
Guidelines for reporting client data should be concise including pertinent information
but no extraneous detail.
Types of reporting:
1. Change-of-shift report
2. Telephone reports
3. Telephone and Verbal reports
4. Care plan conference
5. Nursing rounds
6. SBAR
V. Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of
clinical documentation.