What is the “golden rule” in documentation?

The "golden rule" in documentation states that "If it is not documented, it was not done." This principle emphasizes the importance of thorough and accurate documentation in healthcare settings. Proper documentation is crucial because it serves as a legal record of the care that was provided to patients. If something is not written down, it can be assumed that the action or procedure did not take place, which can lead to legal issues and negatively impact patient care.

Good documentation reflects the patient’s condition, treatment provided, progress, and communication with other healthcare professionals. It also ensures continuity of care, as other providers can refer to the record to understand what has been done previously and what might be needed next. This principle underlines the fundamental role that documentation plays in maintaining high standards of patient care and accountability within the healthcare system.