When documenting, what guidelines should be followed? Select all that apply.

A. Documentation should express the nurse's opinion: Nursing documentation must remain objective and based on observable, measurable data rather than personal opinions or interpretations. Subjective opinions can introduce bias, reduce clarity, and may have legal implications if the record is used in clinical review or litigation. B. Documentation should include abbreviations when possible: Use of abbreviations is restricted to those approved by the facility to prevent misinterpretation and medication errors. Many abbreviations are prohibited due to safety concerns, so indiscriminate use can compromise clarity and patient safety. C. Documentation should be complete: Comprehensive documentation ensures that all relevant aspects of patient care, including assessments, interventions, and responses, are clearly recorded. Complete records support continuity of care among healthcare providers and reduce the risk of omissions that could negatively impact patient outcomes. D. Documentation should be factual: Documentation must be based on objective data, such as vital signs, observed behaviors, and direct patient statements. Factual recording ensures reliability, supports clinical decision-making, and provides a legally sound account of the care delivered. E. Documentation should be accurate: Accuracy is essential to ensure that all recorded information reflects the patient’s true condition and the care provided. Errors in documentation can lead to inappropriate interventions, compromised patient safety, and legal liability for healthcare providers.