Why Is Documentation Important in Nursing Profession?

Documentation is extremely essential in the nursing profession. It plays an important role in monitoring and maintaining the standard of care given to the patient. All the nursing process done to a specific patient needs to be recorded so that the rest of the healthcare providers who are involved in taking care of that patient would know the interventions already given.

The importance of documentation may vary on different venues for as long the information is needed and for whatever purpose it may serve to different cases. Here are some circumstances that the nursing documentation is an essential aid or medium to get a positive conclusion to an issue.

As a Legal Document

In court, there are a lot of crimes or cases which is relevant and related to medical issues. Nursing documentation can be a strong evidence to a lawsuit that will help in solving the case. All nursing interventions listed in the notes are considered to be accurate and reliable. If a specific action was not written in the documentation, this particular intervention is not valid even it was given by the nurse. The nurse who signed on the notes will be the one to defend the content of the documentation and might be subject to any sanction if there are some compromising details related to the case.

To determine the authenticity of a legal document, it must contain the following:

  • Make sure to notarize the document as a true copy through a licensed lawyer.

  • Documents to be used in any legal processes must be duly signed by a licensed attorney.

  • The document must be signed by the attorney-in-fact with his/her full name, address, marital status, and must be at legal age.

Studying the Nursing Profession

The nursing schools must be teaching the process of documentation as part of their curriculum from its basic procedures to advance. It is one of the important tools of studying nursing and to practice the profession effectively. Nursing Process is known to be a scientific method being used in the nursing profession to ensure the best care they can give to the patients. The five phases of the nursing process to provide an excellent care to the patients are:

  • Assessment – the process of investigating the objective and subjective aspect of the patient.

  • Nursing Diagnosis – giving a judgment related to the actual or possible health of the patient.

  • Planning – this is the phase where the nurse already checking the interventions and actions needed for the wellness of the patient.

  • Implementation – the phase where you need to execute the planned intervention with the continuous monitoring of the patient’s condition.

  • Evaluation – this is where to determine if the goal of care met or still need additional actions to improve the care given to the patient.

 A Tool for Nursing Research and Case Studies

Documentation is a powerful tool to be used in a nursing research or any case study. All passed information and medical data can be studied again if there are any cases like epidemic, pandemic, or even to update the current morbidity and mortality rate of the entire population. Documentation in nursing profession is relatively the most important tool to be used in maintaining the global standard of giving proper care to the patient, that can be passed on to the next generations of nurses all over the world. For more information about documentation in the nursing profession and other relevant articles with regard to nursing process, click here.

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