Purpose of Nursing Documentation

Purpose of Documentation

Communication

The primary purpose of documentation of client care is the communication among health care professional to promote continuity of care among departments throughout 24 hours.

Quality Assurance

It provides substantiation of quality of care. An audit is a review of record.

Reimbursement

Reimbursement for client care by insurance companies and other agencies are done after a review of client’s records.

Legal accountability

It serves as legal document. It may be used as evidences in court proceedings.

Research

Nursing and health care research is often carried out by studying client records.

Diagnosis

Documents are aids in diagnosis of patients’ condition

Evaluation

Patient condition progress towards diseases condition will be evaluated based on his/her record.

Assessment

The nurse and other health care members gather assessment data from the client records.

Education

Members of the health team including students utilize these records as an educational tool.

Vital Statistics

Client records, registers and reports furnish the vital statistics.

Health Service Planning

Client record points out the health problems of the country and provides a baseline for local, state, national and international health service planning.

Mr. Arul is admitted in the Medical ward with fever. His temperature was 102°F. Sister Lucy gave Tab. Paracetemol at 8am and went. At 08.10 am, Sister Mary came and checked the temperature, it was 102°F. So, Sister Mary also gave one more Tab. Paracetemol.

Mr. Arul did not tell Sister Mary that he took one tablet already. Patient had 2 tablets instead of one tablet. It comes under Negligence and Malpractice, which is one of legal issue. This is due to the poor communication between the sisters. Even if not able to communicate they should have entered in the patient chart. Patient chart is an ideal way of communicating the information to the next person. Since Sister Lucy did not record or enter in the chart, Mr. Arul had two tablets. This incident tells about the importance of recording and report.