Definition of nursing documentation

Nursing documentation is essential for good

clinical communication. Appropriate legible
documentation provides an accurate reflection of nursing
assessments, changes in conditions, care provided and
pertinent patient information to support the
multidisciplinary team to deliver great care.
Documentation provides evidence of care and is an
important professional and medic legal requirement of
nursing practice.
 The Purpose of Nursing
Documentation
• A written record of the history, treatment, care, and
response of the client while under the care of a health
care provider.
• A guide for reimbursement of care costs.
• Evidence of care in a court of law. A legal record that
can be used as evidence of events that occurred or
treatments given.
• Show the use of the nursing process. It contains
observations by the nurses about the client's condition,
care, and treatment delivered.
• Provides data for quality assurance studies and shows
progress toward expected outcomes.
 ?
The Benefits Of Nursing
Documentation
Nursing documentation has important benefits seen from sharing
aspects such as:
• LAW
All records of information about clients are legal and legal
documents. If there is a problem (misconduct) related to the
profession of keperwatan, and can this as evidence in court to protect
nursing services (nurses), therefore in entering the data must be clear
both time and date of implementation.
• SERVICE QUALITY
Data documenting the data must be complete and accurate,
will provide convenience for parawat in helping solve client problems
and to know the extent to which halal can be resolved. this will help
improve the quality / quality of nursing services
• COMMUNICATION
The client state documentation is a "recorder" tool for client-
related issues. Nurses or other health professionals can view the
existing documentation and as a communication tool that is used as a
guide in providing nursing care.
• FINANCE
Documentation can be financial value of all nursing care that
has not been, is, and has been given is fully documented and can be
used as a reference or consideration in the cost of nursing for the
client.
• EDUCATION
Documentation has educational value, because its contents
concerning chronology of nursing care activities that can be used as
material or reference of learning for learners or nursing profession.
• RESEARCH
Nursing documentation has research value. The data
contained therein contain information that can be used as material or
object of research and development of nursing profession.
• ACCREDITATION
Through nursing documentation will be able to see how far
role and function of nurse in giving nursing care to client. This is in
addition beneficial for improving the quality of service quality also for
individual nurses in achieving higher levels of rank.
 Why Nursing Documentation is
Important?
because as a legal basis of nursing actions
that have been done if someday there is a
demand from the patient.
 jurnal
https://www.rch.org.au/rchcpg/hospital_clinical
_guideline_index/Nursing_documentation/