Which is the BEST example of correct nursing documentation?

Documentation principles: (1) OBJECTIVE — what you see, measure, hear, smell; not what you infer or feel; (2) SPECIFIC — exact measurements, locations, times, doses; (3) FACTUAL — direct quotes from client when appropriate; (4) TIMELY — document as soon as possible after care; (5) COMPLETE — addresses assessment, intervention, response; (6) LEGIBLE/ACCURATE — if paper, neat; if electronic, in correct fields. Words to AVOID: 'seems,' 'appears,' 'looks like,' 'doing fine,' 'normal,' 'good,' 'OK' (subjective/vague); 'accidentally' or 'mistakenly' (legal implications); judgmental descriptions ('difficult patient,' 'demanding family'). DAR documentation: Data (objective and subjective findings), Action (what you did), Response (client's response to your action).

Soap: Subjective, Objective, Assessment, Plan. Charting by exception: only documenting deviations from established norms. Late entries: marked as 'late entry' with current date/time, then describe event with original date/time. Errors: single line through, write 'error' or 'mistaken entry,' initial and date — never erase, white-out, or obliterate. Documentation may be the only evidence in legal proceedings; chart as if you'll be asked to defend each entry in court.