Inaccurate Nursing Documentation

The intent of this paper is to inform the audience about the importance and the purpose of each type of nursing documentations. Nursing documentation is the written or electronic legal record of all pertinent interactions with the patient. Documentation will include assessing, diagnosing, planning, implementing, and evaluating (Taylor, Lillis, Lynn, & LeMone, 2015, p. 339). Many of the errors come from inaccurate nursing documentation, and it is important for nurses to avoid those preventable errors as much as possible for patient’s safety. In order to improve, nurses must know effective documentation. Documentation guidelines consist of content, timing, format, accountability, and confidentiality. These are the critical elements in nursing documents, and it is to have complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document. The purpose of flow sheet is to efficiently record routine aspects nursing care. Flow sheet is an important patient record, because it is mainly to promote patient goal achievement, safety, and well-being (Taylor, Lillis, Lynn, & LeMone, 2015, p. 342 & p. 357).
The purpose of patient record is to foster continuity of care through communication, review diagnostic and therapeutic orders, care planning, improve quality process and performance, research, decision analysis, education, credentialing, regulation, legislation, legal documentation, reimbursement, and historical documentation (Taylor, Lillis, Lynn, & LeMone, 2015, p. 345 ~ p. 350). Basically, the main purpose is to foster quality and continuity of care. Without the patient record, the nurse won’t able to know any medical conditions about the patients and how to treat