When documenting in the medical record, do not chart anything you did not witness or chart for someone else.

Name: When documenting in the medical record, do not chart anything you did not witness or chart for someone else.
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This is a basic principle of medical documentation known as "if you didn't document it, it didn't happen." Documenting something you did not witness or charting for someone else can be considered falsification of medical records and can have serious legal and ethical consequences.

When Documenting in the Medical Record, Do Not Chart Anything