Professional Documentation Practices

1.      Always use respectful person first language about the person you support.

2.      Always complete documentation in a timely manner.

3.      Always indicate time stamps for your documentation.

Additional Rules for Handwritten Documentation

1.      Use black or dark blue ink pen because this photocopies better. It also shows up better when documentation needs to be faxed.

2.      Write in a legible manner. Remember, many people will be reading your handwriting.

3.      Always sign what you have written.

4.      If you make an error in your documentation, place a straight line through the error, initial the error, and then continue with your documentation.

5.      Use all the lines in your logbook. Place lines through any unused space that your signature may cover.

Additional Rules for Handwritten and Electronic Documentation

1.      NEVER go back into an electronic entry and change information, even if the software used allows correcting entries. It is always better to create a new entry that explains inaccuracies or errors. Avoid using cut and paste features unless you carefully check your entry for accuracy.

2.      NEVER document an incident or event for another person. If there are two staff members that witness an incident, each person must complete separate documentation.

3.      NEVER sign something that someone else documented. Complete your own documentation.

4.      DO not use abbreviations that most people will not understand. If there are acceptable abbreviations at your agency you may use them. However, be sure that they are listed with the documentation for all people to see.

5.      NEVER erase a mistake or use White Out or Liquid Paper to correct an error.

6.      NEVER use a pencil or erasable ink.

Reminder!

Every employer is different and may have specific policies and guidelines for documenting information. As a direct support professional, you should always check with your employer or supervisor for specific policies and procedures that will guide your documentation practices.