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Nursing Documentation - Term Paper Example

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Nursing Documentation

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. For groups of client, this document provides information about therapy groups and public health programs service records hence nurses record overall observations pertaining to the group (Carpenito, 2009). Reasons for nursing documentation Nursing documentation usually help in facilitating communication, it provides good nursing care and it meets professional legal standards. Facilitation of communication Nurses usually communicate with other nurses, client and family members of client. In addition, documents usually show interventions that nurses used and outcome from them and care provided to the client by health team (Lippincot & Wilkins, 2007). Promotion of good nursing care Documentation is used as a source of fund and it gives management a good picture on how to pay their nurses hence carrying out nursing resources on how nurses produced their job such as if the quality of work given is low or high. Nurses also make decision on work based with outcome information and they make changes from base evidence (Treas, & Wilkinson, 2013). Meeting professional and legal standards Documentation helps management to acknowledge nurses skills and knowledge via nursing client relationship. In a court of law, the client’s health record serves as the legal record of the care or service provided. Measurement of Nursing care and the documentation of that care measures according to the standards. Tools for documentation Documentation has tools such as flow sheets, worksheets and checklists, Care maps and client care plan are some of tools used to describe health records (Treas, & Wilkinson, 2013). Worksheets Nurses use worksheets to classify care provided to manage their time and many rights of the client. They also communicate surgeries, upcoming test and available orders in the clinic. Client care plans Client care plan are outlines of individual care and they make permanent health record I hospital. They also used to record clearly the wishes and needs of client. Flow sheets and checklists Flow sheets and checklists are also used in document routine care, observations and records kept on a regular basis, and there are permanent health ...Show more

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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…
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