What is the golden rule of documentation?

Asked by: Miss Aurelie Kihn  |  Last update: May 8, 2025
Score: 4.2/5 (39 votes)

Remember the Golden Rule: If it isn't documented, then it wasn't performed. Reviewers do not know the services provided if there is no documentation. You are paid for what you document, not what you did.

What is the most important rule of documentation?

The most important rule of good documentation is for it to be as inviting as possible. This means that we should aim to write it in the clearest terms possible without skipping over any steps. We should avoid making assumptions about what our users may know.

What is the golden rule of information?

Necessary, proportionate, relevant, accurate, timely and secure: Ensure that the information you share is necessary for the purpose for which you are sharing it, is shared only with those people who need to have it, is accurate and up-to-date, is shared in a timely fashion, and is shared securely.

What are the 3 rules of documentation?

Documentation should be:
  • Immediate. Managers should take notes right after an incident occurs. ...
  • Accurate and believable. When an outside observer (judge, jury or EEO investigator) is called to judge your side of the story, detailed observations add authenticity. ...
  • Agreed upon.

What are the rules for documentation?

Characteristics of good documentation
  • All relevant information must be recorded.
  • All paper records must be legible, signed and dated.
  • Records must be contemporaneous, accurate and kept up to date.
  • Records must be written in plain English avoiding jargon.

What is the golden rule of project documentation from a legal perspective?

34 related questions found

What is the golden rules of documentation?

1. Thou Shalt Document Timely, Adequately, and Accurately. 2. Thou Shalt Write Legibly.

What are the 3 C's of documentation?

This situation is often the result of not allowing adequate time for documenting at the planning stage or not starting the documentation task early enough in the project lifecycle. So how does your project or process documentation stack up against the 3 C's of compliance, consistency and completeness?

What are the dos and don ts of documentation?

The Dos & Don'ts of Documentation
  • DON'T copy information.
  • DON'T use vague terms.
  • DON'T use P.U.T.S. in place of the patient's signature.
  • DO support medical necessity.
  • DO be specific.
  • DO be truthful.
  • DO document treatment results.

What are 5 protocols of documentation?

There are five primary guidelines that ensure efficient quality documentation. They include; keeping the documentation factual, accurate, current, organized, and complete.

What are the three elements of good documentation?

Instead of focusing on the mechanics of the customer information experience, a focus on the information experience itself enables us to discern three key elements for quality documentation: discoverability, readability, and usability.

What is the basic golden rule?

Do unto others as you would have them do unto you.” This seems the most familiar version of the golden rule, highlighting its helpful and proactive gold standard.

What is the famous golden rule?

The Golden Rule was proclaimed by Jesus of Nazareth during his Sermon on the Mount and described by him as the second great commandment. The common English phrasing is "Do unto others as you would have them do unto you".

What is the literal golden rule?

This rule is a modification of the literal rule. It states that if the literal rule produces an absurdity, then the court should look for another meaning of the words to avoid that absurd result.

What is the key to good documentation?

Key attributes of 'good' documentation

Study documentation, including signatures, should be easy to read, understandable, and identifiable. Information should be recorded as it happens and the information recorded within study documentation should flow in a correct and appropriate timeframe.

What is the basics of documentation?

Documentation is the written and preserved history of a project, product, or process. The documentation tells us what we did, how we did it, and why we did it that way. This documentation can be in the form of requirements documents, user manuals, technical documentation, or even simple project planning documentation.

What is the most important part of documentation?

One of the most important aspects of your technical documentation is to make sure it's accurate. It should be carefully proofread, tested and reviewed before you publish anything online or in print.

What are the 6 C's of documentation?

Creating Standout Documentation: The Six C's of Technical Writing Excellence. Clear, concise, complete, consistent, correct, and consumable: these six critical attributes elevate technical documentation from average to outstanding.

What does good documentation look like?

Documentation should be pleasant to look at and user friendly. Readers need to find comfort when going through documentation. The experience should be painless and the information should be presented in an engaging way.

What is the principle of documentation?

Your documentation must be precise and coherent so others can understand. Vague and obscure documentations can lead to misinterpretation. Documentation should be specific and individualized to each client. Your documentation should balance being comprehensive and concise.

What makes bad documentation?

Poorly organized, with scattered information, dense paragraphs of text and no images. Doesn't take into account other organizational guidance and workflows. Unclear references, external links or dependencies. Tested for completeness (no missing steps).

What should you not do when documenting?

Don'ts
  1. Don't chart a symptom such as “c/o pain,” without also charting how it was treated.
  2. Never alter a patient's record - that is a criminal offense.
  3. Don't use shorthand or abbreviations that aren't widely accepted.
  4. Don't write imprecise descriptions, such as "bed soaked" or "a large amount"

What are the four documentation techniques?

I stumbled on this model of software documentation that states there are four kinds. Tutorials, how-to's, explanations, and reference documentation.

What are the six principles of documentation?

ALCOA-C stands for Attributable, Legible, Original, Contemporaneous, Accurate, and Complete. These six principles are the foundation of Good Documentation Practices, ensuring that all documentation is reliable, traceable, and compliant with regulatory standards.

What does 3 C's stand for?

The 3 Cs of Brand Development: Customer, Company, and Competitors.

What are the four important points of documentation?

The four C's of documentation—Capture, Categorize, Control, and Convey—are fundamental principles guiding effective document management: Capture: This initial step involves collecting documents from various physical or digital sources.