Nursing Documentation

Term Paper # 101733

Communication
Medical and Health > Nursing

This paper discusses the importance of problems with nursing documentation.

1,482 words () | 5 sources | APA | 2008 United States

Paper Summary:

The paper explains why accurate nursing documentation is vital for quality care. The paper explores the problems with documentation, some of which are based on a distorted nursing perspective and others that are of a systemic nature. The paper provides a number of solutions and recommendations to these problems.

From the Paper:

"Nursing documentation is a highly significant issue since documentation is a fundamental feature of nursing care. Patient records are legally valid, and need to be accurate and comprehensive so that care can be communicated effectively to the health care team. Unless the content of documentation provides an accurate depiction of patient and family care, quality of care may not be possible. Many nurses do not realize that what they document or fail to record can produce an enormous effect on the care that is provided by other members of the health care team. More importantly, the nurse's attitude as documentation proceeds, determines how other members of the interdisciplinary team will react to the patient and/or family."

Sample of Sources Used:

College of Nurses of Ontario (CNO) (2005). Standard practice: Documentation. Accessed February 14, 2007. http://www.cno.org/
Fernandez, R. & Spragley, F. (2004). Focus on streamlined documentation. Nursing Management, 35 (10), 25-30.
Huffman, M. & Cowan, J. (2004). Redefine care delivery and documentation. Nursing Management, 35 (2), 34-39.
Karkkainen, O. & Bondas, T. (2005). Documentation of individualized patient care. Nursing Ethics, 12 (2), 123-132.
Owen, K. (2005). Documentation in nursing. Nursing Standard, 19 (32), 48-50.