Importance of Nursing Documentation and Purpose
1. Serves as a vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, and delays in client care.
2. Ensure continuity of patient care for future management.
3. Provides evidence for evaluation purposes. For instance, nurse use baseline and ongoing data to evaluate the effectiveness of the nursing care plan. In addition, records and reports assist nurse managers to evaluate staff performance.
4. Serves as an audit tool. Client’s records may be reviewed to determine if a particular health institution is meeting its stated standards.
5. Serves as an educational tool for nursing students. The information contained in a record can be a valuable source of data nursing research.
6. Investigations into complaints about care will look at and use the patient/client documents and records as evidence, so high quality record keeping is essential. The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right. A court of
law will tend to assume that if care has not been recorded then it has not been given.
7. A client’s record is a legal document and is admissible in court as evidence.
8. Aid hospital management in planning. Information from record may assist healthcare planner to identified institutional needs, such as over utilized and underutilized hospital services. They can often establish from record the cost benefit and cost effectiveness of various services and identify those services that cost the hospital money and those that generate revenue.