Nursing Documentation

Documenting objective and subjective data helps to identify and address problems in healthcare, and constitutes an important step in health assessment. Accurate recording of patient data fosters the success of nursing by providing health care teams with data that is vital concerning the evaluation of the effectiveness of treatment plans. Falsification of records within the nursing practice poses significant threats to public health and welfare. Nurses are responsible for monitoring patients and taking relevant decisions and actions depending on a patient’s condition.  Thus, honesty and accuracy in reporting patients’ information are crucial traits that promote safety and effectiveness within nursing care. Timely documentation is a key element of nursing management that ensures the safety of patients (Bernick & Richards, 1994).  This practice enables nurses to maintain consistency in the provision of care due to the accessibility of real-time information on patients.  Timely documentation enhances accuracy of patient records by minimizing errors that arise when one attempts to prepare records after attending to several patients and different cases.

The use of abbreviations and symbols in documentation introduces challenges within the nursing profession due to lack of standardization. In this regard, people may have diverse interpretation of an abbreviation or symbol, which is likely to hamper effective delivery of healthcare. Inadequate knowledge and technical understanding on recording of patients’ care information using technological tools introduces barriers in the attainment of safe and quality health care (Gugerty et al., 2007). Health care teams may misinterpret patients’ information or are unable to access data on the care history of a patient.  This slows down the nursing process. The loss of information for a specific period has adverse effects on the nursing process, which largely relies on a continuous history of patient care. Real-time records illustrate patients’ response to treatment and act as a source of reference in case of undesirable responses by patients under a care plan.