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Characteristics of good documentation

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In your previous discussion, you may have identified some of the following key characteristics of good record keeping:

  • All relevant information must be recorded
  • All paper records must be legible, signed and dated
  • Records must be contemporaneous, accurate and kept up to date
  • Records must be written in plain English avoiding jargon
  • Records must clearly distinguish between statements of fact and opinion
  • Paper records if moved to a new location must be monitored and kept securely

In the next step, we will return to our fictional case study to see what the documentation can tell us about Sofia.

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