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 healthcare 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.