Introduction
                           Introduction
     Documentation in the health record is an integral part of safe and 
      Documentation in the health record is an integral part of safe and 
      effective nursing practice.
      effective nursing practice.
     
     
     Clear, comprehensive and accurate documentation is a judgment 
      Clear, comprehensive and accurate documentation is a judgment 
      and critical thinking used in professional practice and provides 
      and critical thinking used in professional practice and provides 
      an account of nursing’s unique contribution to health care.
      an account of nursing’s unique contribution to health care.
     Effective communication requires to be done in a timely manner.
      Effective communication requires to be done in a timely manner.
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    Nurses should also be aware of the legislative 
      Nurses should also be aware of the legislative 
      requirements regarding documentation that may 
      requirements regarding documentation that may 
      apply to their particular practice setting. 
      apply to their particular practice setting. 
    Effective documentation policies and practice 
      Effective documentation policies and practice 
      take into consideration who the clients are, client 
      take into consideration who the clients are, client 
      needs and available resources. 
      needs and available resources. 
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                Purpose of Documentation
                1. Communication
      Documentation is fundamentally communication 
       Documentation is fundamentally communication 
     that reflects the client’s perspective on his/her health, the care 
     that reflects the client’s perspective on his/her health, the care 
       provided, the effect of care and the continuity of care. 
       provided, the effect of care and the continuity of care. 
      Effective documentation assists clients to make future care 
       Effective documentation assists clients to make future care 
       decisions. 
       decisions. 
      Accurate documentation also reflects the effectiveness of the care 
       Accurate documentation also reflects the effectiveness of the care 
       provided.
       provided.
      Accurate documentation provides a reliable, permanent record of 
       Accurate documentation provides a reliable, permanent record of 
       client information. 
       client information. 
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                         2. Accountability 
                         2. Accountability 
   
    The health record demonstrates nurses’ 
     The health record demonstrates nurses’ 
   accountability and gives credit to nurses for their 
   accountability and gives credit to nurses for their 
   professional practice. 
   professional practice. 
   
    It is used to determine responsibility and may be 
     It is used to determine responsibility and may be 
   used in legal proceedings.
   used in legal proceedings.
   
    Legislative issues: failing to keep records as 
     Legislative issues: failing to keep records as 
   required, falsifying a record, signing or issuing a 
   required, falsifying a record, signing or issuing a 
   false or misleading statement, giving information 
   false or misleading statement, giving information 
   about a client without consent and storage and 
   about a client without consent and storage and 
   retrieval of documentation.
   retrieval of documentation.
   
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                        3. Quality improvement
                        3. Quality improvement
   
     Information from the health record is often used to 
     Information from the health record is often used to 
   evaluate professional practice during quality 
    evaluate professional practice during quality 
   improvement processes, such as performance 
    improvement processes, such as performance 
   reviews, accreditation, legislated inspections and 
    reviews, accreditation, legislated inspections and 
   board reviews (ءانملمما         ). 
    board reviews (ءانملمما        ). 
   
     Clear documentation facilitates the evaluation of 
     Clear documentation facilitates the evaluation of 
   the client’s progress toward desired outcomes. 
    the client’s progress toward desired outcomes. 
   
      It enables nurses to identify and address areas that 
      It enables nurses to identify and address areas that 
   need improvement. 
    need improvement. 
   
     Poor documentation provides incomplete or no 
     Poor documentation provides incomplete or no 
   written evidence of the quality of care provided.
    written evidence of the quality of care provided                         6
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