This lesson provides caregivers with a review of the basic principles of client care documentation, including the ethics and legalities involved in documentation. Discusses the DOs and DON’Ts of documenting client care in a variety of health care settings. Emphasizes the importance of accuracy, attention to detail, and timeliness.

Name at least three purposes of clinical documentation.
Describe the difference between objective and subjective observations.
Discuss the five rules of clinical documentation.
Describe the purpose of an incident report.
Complete documentation according to the guidelines presented in this inservice and the policies of your workplace.