GradStart Nurses' Survival Guide

Documentation is the process of preparing a complete record of a patient's care. This is vital in effective communication among health care team members. Accurate, detailed documentation shows the extent and quality of the care that nurses provide, the outcomes of that care, and the treatment and education the patient still needs. Thorough, accurate documentation reduces the potential for miscommunication and errors. Documentation is a valuable method of demonstrating that a nurse has applied nursing knowledge, skills, and judgement according to professional nursing standards. In a court of law, the patient’s health record serves as the legal record of the care provided to that patient.