1.record observation, not interpretations
2.let the reader draw his own conclusion based on fact
3.avoid judgemental language good job
4.undefined periods of time frequently, seldom
5.use measurable and defined periods
6.undefined quantities some, many
7.use numerical quantities
8.qualities hostile, bored
9.replace with actual observations-describe what the client is doing
10.failure to provide an objective basis for judgement "patient likes trains"
"patient stated he likes trains and will read anything on the subject"
11.give evidence to support statement
- 12.inappropriate use of clinical terminology
- -only a physician can diagnosis the patient "the patient was hallucinating" "the patient appeared to be hallucinating; she was conversing when no one was there"
- 13.avoid jargon:
- -use terms that are understood by all staff
- -if used include a brief explanation
14.omit extraneous detail
16.ensure your notes will be read