Nursing Documentation Essay

Nurses have to write documentation after each procedure they’re doing. It should be written in clear, accurate, concise, understandable language and it has to be up to date. Since health care is changing everywhere and this has a great effect on documenting we should be very careful. Documentation is how the health care team communicate and it is also important for the safety of the patient, and it is both what you observe (objective data) and what the patients say (subjective data) to analyse your data at the end and compare both the sign and symptoms to identify the disease and then identify the appropriate treatment for it. Although, we know how to document but we are still learning more and more during our learning years. What is documentation? Why do we document and what is the importance of documentation? What is the outcome if we commit a mistake while documenting? Who are the people who are viewing the documentation and why are they viewing it?
It is characterized by writing down what the patients says and what is done and what is the outcomes of each medical procedure even the simplest ones (for example taking vital signs of the patient). The importance of documentation is basically to provide lawsuit against medical malpractice (to protect nurses in their practice), in addition, providing quality health and safe care to patients(also protecting the patients’ right). Documentation improves patient outcomes and satisfaction, clinical workflow, coordination of care, and data collection. It also improves team communication and collaboration, greater compliance with recommended practices and national quality and safety standards and increased efficiencies as well as minimizing the risks of errors and negligence .Documentation is used for administrative purposes as well as Planning and