I work in a residential treatment center for adults. We primarily give medications and manage refills. Our office is open from 5am to 11:30p. Should we chart after each interaction or chart by exception? Thanks, John

I would take vitals with each patient and have a list of body systems that I am checking and what my findings are. I want to document that that patient was shinny when they saw me or if they r not shinny I will put it down, symptoms, dr phone call ,.and what I did to help this person.