Chart entries should always?

Chart entries should always include the date and time because accurate documentation is critical in healthcare settings. This practice ensures that all records are timely and reflect the correct timeline of patient care. Including the date and time helps healthcare professionals track the sequence of events, changes in a patient's condition, and interventions provided. It supports continuity of care and is crucial for legal and regulatory requirements, as it establishes a clear timeline that can be referred to if there are questions about the care provided or if further action is needed based on that care.

Other practices, such as writing entries at the end of a shift, using pencil, or employing ditto marks, do not meet the standards of good documentation. Writing at the end of a shift can lead to inaccuracies since it may not reflect real-time observations or changes. Pencil is often discouraged because it can easily be erased or altered, compromising the integrity of the record. Ditto marks may cause confusion and lack clarity, as each entry should be specific to maintain clear and comprehensive records.