What is are the importance of nursing documentation?
Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.
What is meant by documentation in nursing?
Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse [1]. Nursing documentation is the principal clinical information source to meet legal and professional requirements [2].
What are the components of nursing documentation?
Be clear, legible, concise, contemporaneous, progressive and accurate. Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.
What causes poor documentation?
Combs agrees: “The most common cause of poor documentation is a lack of understanding of the specific information that needs to be included for coding purposes.
How can nurses improve documentation?
Tips for Great Nursing Documentation
- Be Accurate. Write down information accurately in real-time.
- Avoid Late Entries.
- Prioritize Legibility.
- Use the Right Tools.
- Follow Policy on Abbreviations.
- Document Physician Consultations.
- Chart the Symptom and the Treatment.
- Avoid Opinions and Hearsay.
What is the purpose of documentation in nursing?
Introduction. Nursing documentation is essential for good clinical communication. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.
What are the best practices for nursing documentation?
The Best Practices in Nursing Documentation. Documentation is mandatory for nurses, as the medical records they produce are considered legal materials. These professionals should maintain accurate information, including a chronology of events that features the date, time and nurse’s full signature after services were provided.
Why is good nursing documentation so important?
Good documentation is an important part of improving both patient care and nursing practice. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. To find out more about the specific documentation standards where you practice, contact your state board of nursing.
What is the definition of documentation in nursing?
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process.
