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Nursing Documentation Name Institution 11th December 2013 Nursing Documentation Introduction Documentation is any written or electrical information that describe the client welfare and care given to him by nurses. Client refers to persons, families, groups, populations or entire communities who require nursing help.
The term records is used in this periodical to mean any written by electronic means generated information about a patient that describes the service or duty of care provided to that client. Health records may be paper documents or electronic documents, such as images, electronic medical records, faxes, e-mails and video record or audio. Body Via documentation, nurses converse their explanations, decisions, procedures and consequences of this deed for clients. Records used as exact explanation of what happen and when it happened, hence they give clear information on them. From documentation, information given to individual clients or groups of clients according to the nature of the individuals relates to the consequences of observation. For individual clients, documentation provides entire statement of the status of the client, the proceedings of the nurse, and the client results. Nursing documentation clearly describes an evaluation of the client’s fitness status, nursing interventions carried out, and the result of these interventions on client impacts. From nursing health chart, care plan records client’s requirement such as goals of clients and wishes. If care plan, needs any change nurses usually report the information to other health care or physician on behalf of client. ...
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