Table 3.

Basic do’s and don’ts in clinical record entries

Do	Do not
Use timed entries	Use abbreviations
Make objective comments	Make offensive, humorous or personal comments
Document any noncompliance	Use ambiguous terms
Document oral communications (phone calls, in person conversations etc) and actions taken	Delete or alter the contents of clinical notes in a way that is untrackable
Document informed consent
State objections regarding care or case management