Question

When writing progress notes your entry must be: on 16

when writing progress notes your entry must be

Answer 1

While writing progress notes entries should be:

1. Given in relevant patient notes after checking identifiers such as name and DOB.

2. In legible handwriting using blue or black ink pens when handwritten.

3. With the date and time of each entry at the beginning. Each entry should be signed after the last word to avoid insertion of additional notes

4. Entry should be without blank space between 2 entries to avoid insertion of additional notes.

5. Each entry with more than one page should be given 'Notes continues to next page' at the end of the page and 'Continued from the previous page' before the next page entry.

6. Entries should be error-free. Strikeout the words with just a line when mistakes are made, don't blackout or whiteout mistakes.  

7. Should be made carefully when using confusing words like dysphagia and dysphasia, anuresis and enuresis etc.

8. Entries should be without abbreviations/acronyms, full words should be used instead.

9. Should be professional without assumptions etc.

9. Entries should be concise focusing on progress and status since the previous entry.

10. Entries should be made with all the necessary information.

11. Patient privacy should be considered.

12. Entries should be without complaints about other staff members.

13. Recommendations and advice from other providers should be included.

14. Entries should be written in SOAP (Subjective, Objective, Assessment, and Plan) format.