Verifying that the acquired subjective and objective data are accurate and dependable is known as data validation.
Maintains confidentiality and records client information in a legible manner using permanent ink
-avoid wordiness that leads to repetition
utilize proper grammar and spelling
-use a phrase or group of phrases to record facts
-Record data results rather than the method of collection.
-write entries in an objective manner without jumping to conclusions
-note the client's comprehension and assessment of the issues
-do not record the word "normal" for findings that are normal.
-enter detailed information about each customer symptom.
-include additional assessment material as necessary
-confirm particular observations made during the physical examination to validate objective data.
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