Nursing Documentation

Documentation

Introduction

Document is described as any written or electronically generated information about a patient status or the care or the service provided to that patient. Nursing documentation is the record of nursing care that is planned and delivered to individual client. Nursing documentation is varied , complex and time consuming depends on the severity of the patient condition.

Records and reports are the essential components for implementation and evaluation of patient care in the hospital or community. Hence the documentation is consider as an integral part of nursing practice, and is necessary to ensure high quality of patient care. This chapter is to discuss about the importance of documentation which includes recording and reporting. The Nursing and Midwifery Council (NMC 2002) stated that ‘good record keeping helps to protect the welfare of patients.