Reporting/Documenting Client Care


Reporting/Documenting Client Care



This lesson provides caregivers with a review of the basic principles of client care documentation, including the ethics and legalities involved in documentation. Discusses the DOs and DON’Ts of documenting client care in a variety of healthcare settings. Emphasizes the importance of accuracy, attention to detail, and timeliness.

  • Name at least three purposes of clinical documentation.
  • Describe the difference between objective and subjective observations.
  • Discuss the five rules of clinical documentation.
  • Describe the purpose of an incident report.
  • Complete documentation according to the guidelines presented in this inservice and the policies of your workplace.


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