Gap Medics is one resource nursing students and beginning nurses can use to learn more about successful charting and documentation. All Nurses also features guides on proper medical documentation and charting.
Many of the guides focus on basic standards that nurses should keep in mind as they write out their documentation, such as staying objective and keeping accurate reports of time and medication. Other advice includes writing legibly and making sure not to leave any personal opinions or remarks in the documentation. Knowing the abbreviation policy for the facility of employment is also vital, as many facilities follow different abbreviation standards.