The Importance Of Documentation In Nursing

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According to Johnson, B. B. (2011, p.8) nursing documentation has been reported as a core component of nursing care. He said that it is a prerequisite for quality care to facilities efficient communication and cooperation among health professionals as well as effective coordination. In this essay will discuss about the importance of documentation, the factors that affect documentation, common errors in documentation and the ways to improve documentation for nurses. Nursing documentation is very important for nurses as well as patients. This is because it may be used as evidence to either incriminate or exonerate for nurses in case of lawsuits (Jefferies, Johnson, & Griffiths, 2010, p.113). For example from my case scenario, the morning staff nurse forgotten to record the NGT insertion procedure into Mr. Tan’s case file. This will cause her lack of evidence support in case of lawsuit due to no documentation was recorded if something had happened to Mr. Tan. Law, Akroyd & Burke, (2010, p.1228) had said that not documented work considered work not done. In this case, the morning staff nurse can be consider that she did not perform the NGT insertion. In other words, incomplete and careless documentation can indicate that nurses are not providing standard care that supposed to be done to patient (Blair & Smith, 2012, p. 162). Good documentation can ensure appropriate reimbursement and providing a database for planning future healthcare. So it is very importance for nurses to

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