Documentation In Nursing Practice

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Documentation is anything written or electronically generated that describes the status of a client or the care or services given to that client (Perry, A.G., Potter, P.A., 2010). Nursing documentation refers to written or electronically generated client information obtained through the nursing process (ARNNL, 2010).
Nursing documentation plays a significant role in nursing practice. Documentation can be either paper or electronic which is used to observe the improvement of a client. It a way to convey information such as assessment, interventions require with reference to the client’s history along with the effectiveness of those interventions. It also encourages continuity of care as it allows other members of the healthcare team to access

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Health Information Management

Association (2010) the use of a standardized nursing language for documentation of nursing care is both vital to the nursing profession and to direct nursing care. As of 2008 the American…

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Essay about Professional Portfolio: Tracking Personal Development

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and appropriately? The quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry (Dehghan, Dehghan, Sheikhrabori, Sadeghi, & Jalalian, 2013). Keeping documentation accurately and appropriately, while dedicating our time to patient care is tantamount to delivering safe care; it is part of our duty to work and develop a safe environment. The quality of our documentation reflects the quality of our nursing care despite of the acuity or level…

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INTRODUCTION In this case study, Mr. Mustafa, a registered nurse, neglected the codes of conduct, ethical principles, and standards of practice for nurses, as he failed to assess neurological observations on an 80-year-old resident named John after he fell in an aged care facility's dementia unit in Melbourne, due to Mr. Mustafa being busy with documentations and doctors’ rounds. Alarmingly, Mr. Mustafa did not record the fall-in-history medical records. John seemed settled without any reason for…

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Veterans Affairs, 2010). Therefore, to provide and maintain excellence in care, it is necessary to improve constantly. Health laws require documentation of nursing interventions performed and evaluation of the care given to ensure and improve nursing care quality (Muller-Staub, 2009). In 2001, the MVAMC changed the paper-based nursing documentation system to…

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