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‘’If it isn’t written down, it didn’t happen’’
Providing evidence is essential when you document patient care. Record-keeping varies enormously in healthcare. Some people do it really well, and some do it very poorly. Some think that if they communicate things to a colleague verbally, they don’t need to write things down. They think if they do a fantastic handover, cursory record-keeping is sufficient. But this isn’t the case. While communication is one aim of record-keeping, just as important is accountability, explaining what you observed and the actions you took.
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