Documentation completed contemporaneously, or a late entry noted per policy.
Signature with credentials applied; license/state included if required.
Co-signature obtained if required.
The pre-flight discipline
A note that clears all eight blocks carries its own defense: it proves the day happened, the resident qualifies, a skilled service was required today, the MDS is supported, the care plan is current and linked, teaching produced learning, coordination and notification closed the loop, safety and restraint/psychotropic rules were met, and the record is validly signed. Run the check before signing — not after an ADR determination or a survey exit.
