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you as a health care provider documentation is a big part of your daily activities sometimes it probably seems like such a big part that it overshadows everything else making you feel caught in an endless maze of medical records this training video provides some helpful tips on how to improve your documentation skills good documentation benefits both the patient and you your organization may be using an electronic documentation system or you may still be using a paper record there are positive and negative aspects to both bottom line whichever system is used the perception is if it wasnt documented it wasnt done complete documentation is the key lets talk about some documentation dues when using a paper client record do write legibly a record cannot be a useful communication tool between disciplines if no one other than you can read your notes do use approved forms these forms are generally set up to capture required information assessment tools and checklists when used consistently
