The document discusses the importance of accurate and complete charting including: documenting the correct time and date of entries, avoiding unclear or ambiguous entries, and not including opinions or conclusions without supporting evidence. It provides examples of problematic charting entries and emphasizes documenting assessments, following chronological order, and avoiding abbreviations. The document stresses the implications of charting for litigation, licensure, audits and reimbursement.

1. Charting for Keeps MK Gaedeke Roland, RN, MSN, JD Associate General Counsel Kaleida Health