Evaluating Nursing Documentation

When talking about nursing documentation, what come to the mind is that, the feeling of dread if being a prisoner because of documentation error regardless either a grammar error or the way the documentation sentences being presented, which then it can be twisted by other parties to charge the nurse as guilty person. Nursing documentation is a legal documentation where this document will be the evidence for hospital staff to defense themselves in case of any incidences that lead to court hearing. According to Ward a freelance online author and writer for Elsevier Medical Publishing (2012), the medical record is the greatest powerful tool for attorneys, legal experts, and expert witnesses use in order to examine the type of care the patient

Documentation is evidence that the patient received proper care. This mean that, what is been documented is what had been done to the client, while what was not been documented indicate that were never been done to the client. Besides, the way of the documentation been written also play an important role. Documentation is a resources for others to assess whether the care that a patient received was met the professional standards for safe and effective nursing care, or otherwise. As well, various people whom read the report will have different kind of interpretations on what had been done.

On the other hand, issue related to nursing documentation are such as illegible nursing documentation, misspelled words and poor grammar. Sometimes, nurses’ records can be confusing, intriguing, and sometimes downright comical. Grammar and syntax problems are frequently at the heart of documentation bloopers. Thus, a clear, concise documentation is very important. The nurse educators should emphasize the importance of proper grammar and syntax in documentation, and instruct nurses to cross-check their notes with another healthcare professional if they suspect their entry is