In healthcare documentation, a common rule states "if it is not _____, it was not _____."

The principle "if it is not documented, it was not done" emphasizes the critical importance of thorough documentation in healthcare. This rule serves multiple functions: it ensures accountability, maintains accurate medical records, and provides legal protection in case of disputes regarding the care provided. In a healthcare setting, every intervention, observation, and plan must be clearly documented to reflect what has transpired during patient care. Without proper documentation, there is no evidence to support the actions taken by healthcare professionals, which can lead to significant implications for patient trust, continuity of care, and legal matters.

While other phrases may suggest similar ideas about recording and observing, they do not encapsulate the overarching legal and professional obligation that is underscored by the principle of documentation in healthcare. The necessity for documentation as the official record of care is paramount in ensuring patient safety and quality healthcare delivery.