Nursing Documentation

The three articles reviewed in this paper present the importance of documentation and the impact it has on patient safety. In health care, patient records are an essential source of information. Therefore, proper documentation is very important. Patient records are also used for legal and research purposes. Good standards in documentation should always be maintained. Proper documentation is still a challenge in nursing. Studies are constantly being conducted to explore different strategies that could be used to improve documentation. The quasi-experimental study conducted by Dehghan, Sheikhrabori, Sadeghi, and Jalalian (2013), showed the impact the implementation of clinical governance had on the quality of nursing documentation. Clinical governance

Frank-Stromborg, Christensen, and Elmhurst (2001), analyzed data from various sources including legal journals, the internet, nursing, and case laws about proper nursing documentation and the liability involved in improper documentation. Frank-Stromborg et al. (2001), first discuss the general principles of documentation. One of the components of documentation in a complete and accurate record of the patient’s status and care provided. Frank-Stromborg et al. (2001), also examined studies that analyzed reasons why nurses do not always document care adequately. Studies show that there are numerous barriers to proper documentation. This includes lack of staff, heavy-patient loads, cumbersome charting formats, and not having enough time to chart. Furthermore, Frank-Stromborg et al. (2001), described the different formats of documentation and the pros and cons of advanced technology in healthcare. Patient confidentiality can be breached by faxing patient information, using the telephone, and through email. Computer charting has several advantages including increased accuracy and easy access to information. After synthesizing various forms of data Frank-Stromborg et al. (2001), concluded that educating nurses about the principles of documentation improves patient care and protects the institution and its medical professionals from

The article presents the importance and implementation of nursing documentation and discusses the application of electronic documentation systems. Nurses’ documentation serves many purposes. It is essential in monitoring patient outcomes, is important for the quality improvement process, and can make a difference in who pays for medical care. Alkouri, AlKhatib, and Kawafhah (2016), state that documentation includes important aspects such as a legal evidence of care, provides a way to assess efficiency of care, provides data and evidence for research, can be used for financial quality assurance purposes, provides a database to support nursing knowledge, and helps improve nursing education and clinical