Nursing documentation

Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal and professional requirements, and one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients. Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal and professional requirements, and one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients. The internationally accepted nursing process consists of five steps: assessment, nursing problem/diagnosis, goal, intervention and evaluation. Nursing process model provides the theoretical framework for nursing documentation. A nurse can follow this model to assess the clinical situation of a client and record a constructive document for nursing communication. Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process. The following sections describe the concept, aim, possible structure and content of these nursing documents using the example of nursing documentation in Australian residential aged care homes. An admission form is a fundamental record in nursing documentation. It documents a client's status, reasons why the client is being admitted, and the initial instructions for that client's care. The form is completed by a nurse when a client is admitted to a health care facility. The admission form provides the basic information to establish foundations for further nursing assessment. It usually contains the general data about a client, such as name, gender, age, birth date, address, contact, identification information (ID) and some situational descriptions about marriage, work or other background information. Based on the different nursing care provider's requirements, this form may also record family history, past medical history, history of present illness, and allergies (see Figure 1). The documentation of nursing assessment is the recording of the process about how a judgment was made and its related factors, in addition to the result of the judgment. It makes the process of nursing assessment visible through what is presented in the documentation content. During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. The nursing documents may contain a number of assessment forms. In an assessment form, a licensed Registered Nurse records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing assessment determine the accuracy of care planning in the nursing process. The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriented rather than nursing-process-based. Nowadays, the NCP is widely used in nursing in various clinical and educational settings as a tool to direct individualized nursing care for clients.