Competency information

Details

Maintain an ongoing, accurate, relevant and legible record of information in the patient record

Considerations

  • Requirements for documenting all assessment findings legibly, accurately and appropriately in the patient record, with date and signature
  • Requirements for data in a suitable form for clinical reporting and provision of factual assessment of results

Relevant learning outcomes

# Outcome
# 5 Outcome Maintain an ongoing accurate, relevant and legible recording of information in the patient record