What is required when completing a note in a paper chart?

When completing a note in a paper chart, it is essential to include your name and identification number adjacent to the entry. This practice ensures that the documentation is traceable and identifiable, which is crucial for maintaining accurate and reliable patient records. By including both your name and identification number, it provides clear accountability, allowing others to verify the source of the information and any associated clinical decisions made during the patient's care.

In a professional setting, thorough documentation serves multiple purposes, including legal protection, quality assurance, and continuity of care. This requirement helps to uphold standards of practice and increases the integrity of the patient record, making it easier to navigate and address any potential concerns or questions that may arise in the future.