What it means
Everything a nurse writes in the client's health record: assessments, care given, medications, teaching, the client's responses and communication with other team members. It lets the team share information, proves what was done, supports billing and research, and is a legal record. Good documentation is accurate, factual, timely, complete and objective.
For the nurse
Record only what you saw, heard or did, in the client's own words when quoting. Document as soon as possible after care, never in advance, and never for someone else. Correct an error by the facility's method; never erase or delete it.
In a chart
"1430: Client states 'my pain is a 3 now.' Resting with eyes closed, respirations 16 and even."
Remember it
If it was not documented, it was not done.
At a glance
| Spanish | documentación |
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Related terms
handoff report
The passing of information and responsibility for a client's care from one nurse or team to another.
standard of care
The level of care that a reasonably careful nurse with the same training would give in the same situation.
negligence
Failure to use the care that a reasonably careful person would use in the same situation.
informatics
The use of information technology and data to support health care and decisions.