If the entry is late, document the current date and time, identify the entry as a late entry, and document the date of the event . Keep in mind that the reliability, completeness and accuracy of progress notes charted in an untimely fashion will be questioned in a lawsuit. It should go without saying that no entry should be altered in any fashion. Do not use erasable pens or pencils in a patient's charts. Every item on preprinted forms should be answered.
Legibility is also very important.
Be sure to pay particular attention when signing your name. Use only abbreviations that are approved. Always document the patient's behavior, especially non-compliant behavior. Be sure to document objectively when faced with a difficult patient. Be factual rather that judgmental.