Nursing Process::DOCUMENTATION

BY : CATHERINE KUCKYT, RN

Purpose of Documentation

Communication

Documentation is fundamentally communication that reflects the client´s perspective on her/his health and well-being, the care provided, the effect of care and the continuity of care. All health care providers need ongoing access to client information to provide safe and effective care and treatment.

Effective documentation allows nurses and other care providers to communicate about the care provided and to assist clients to make future care decisions.

In addition, documentation provides a legal record of care provided.

As an CNO Instructor(D.R.) once said, "If it isn´t documented you didn´t DO IT !"
A nurse maintains documentation that is:

* Clear, concise and comprehensive;
* Accurate, true and honest;
* Relevant;
* Reflective of observations, not of unfounded conclusions;
* Timely and completed only during or after giving care;
* Chronological;
* A complete record of nursing care provided, including assessments, identification of health issues, a plan of care, implementation and evaluation;
* Legible and non-erasable;
* Permanent;
* Retrievable;
* Confidential;
* Client-focused
* ;and Completed using forms, methods, systems provided or, in independent practice, using practitioner-created forms, methods and systems consistent with these standards.

A nurse´s documentation:

* Includes date and time of the care or the event, and the recording of when it is a late or forgotten entry;
* Identifies who provided the care;
* Contains meaningful information, avoids meaningless phrases such as "good night," "up and about," or "usual day";
* Includes what was observed and avoids statements such as "appears to" and "seems to" when describing observations;
* Includes signatures or initials, and professional designation; and
* Avoids duplication of information in the health record.