Make notes within the first 24 hours of an event. Date everything , even a change in an original note. Make notes legible. Either write clearly or use a transcription service. If you use dictated records, always proofread.
Mistakes are the physician's responsibility.
Avoid ambiguous abbreviations Make corrections by drawing a single line through the original note and add the new one along with the date, time, and your initials. Never enter derogatory remarks about another provider Note differences between your judgment and a managed care plan's rules. Don't criticize the plan, simply state that you believe that such and so is indicated but your opinion does not meet the plan's criteria. Document all telephone calls and conversations with patients and family members. Document all potential complications Be specific with informed consent.