The Importance Of Documentation In Nursing

Nursing is one of many healthcare profession in the medical field. There are many legal measures within nursing. One major essential part in nursing is documentation. Documentation plays a very important part when it comes to any profession. Documentation starts right when someone enters the door in the medical field and doesn’t ends until after discharge of the patient. There are many different areas of documentation in which is completed by a nurse. What’s documented by a nurse is all aspects of the nursing process, plan of care, admission, transfer, transport, discharge information, client education, medication administration, incident reports, verbal and telephone orders, advance directives and also collaboration with other health care

The principles of documentation is clear, confidential, accurate, complete and concise, objective, organized and timely. Using documentation nurses are required to legally and ethically keep all information in the patient record confidential. There is the Health Insurance Portability and Accountability Act, known as HIPAA, which helps gives patients a greater control over their health care record (). Precise measurements and times must be used as much as possible. Accuracy can be enhanced through point of care documentation (Craven, 2017). The accuracy of documentation can be view from three perspectives veridical reflection of nursing, comprehensive while through detail of a patient journey and finally clarity in usage terms (Britain Summer of Nursing). The accuracy part is the really vital part in documentation within nursing because it shows the complete reflection of the stages of care that was provided by the health care professionals to an individual. Next, when an individual is documenting it needs to be complete and concise and organized. Having the report done as so allows for any health professional to find any information quick as possible without having to search throughout the entire chart for answers. When reporting it needs to be in a chronical flow order of the information about the patient care and procedures being done, within the chronological

Documentation is a form of communication that provides information about the patient and confirms that care was provided to that patient. Some reasons why nurses document is for communication and continuity of care of the patient and by that it means clear, complete and accurate documentation in a health record ensures that all those involved in a client’s care, including the client, have access to information upon which to plan and evaluate their interventions. Next, quality improvement/assurance and risk management through chart audits and performance reviews documentation is used to evaluate quality of services and appropriateness of care. Additional reason is it establishes professional accountability because documenting that is showing a valuable method of demonstrating that nursing knowledge, judgment and skills have been applied within a nurse-client relationship in accordance with the Standards of Practice for Registered Nurses. Another purpose is for legal reasons the client’s record is a legal document and can be used as evidence in a court of law or in a professional conduct proceeding. Courts may use the health record to reconstruct events, establish time and dates, and refresh one’s memory and to substantiate and/or resolve conflicts in testimony. Although you may never be named as a defendant in legal case, you may be called to testify at a discovery or