Documentation
Standards
Basic Charting
Guidelines
ØOnly universal and county designated
acronyms are
accepted.
ØDo not use the name of other client(s) in the charting.
ØDo not “rubber stamp” your verbiage.
ØAlways attempt to obtain the client’s
signature where
indicated. If the client is unable or unwilling to sign, note it on the signature line,
date it, and document
why the client refused to sign or note inability to sign.