Nursing documentation is a vital component of safe, ethical and effective nursing practice,

regardless of the context of practice or whether the documentation is paper-based or

electronic. Documentation is a nursing action that produces a written and/or electronic

account of pertinent client data, nursing clinical decisions and interventions, and the client’s

responses in a health record (Perry, Potter, Stockert & Hall 2017). Documentation is an

integral part of professional nursing and safe practice and is not optional. The basic purpose

of nursing documentation is the creation of a database or a health record of a client’s

experience with the health care system (Evans, 2016).

Nursing documentation demonstrates what the nurse does for/with the client and is one part

of the broader inter-professional documentation that forms the client health record. The

health record is made up of a number of inter-professional tools and documentation that

provides evidence of the care, treatment or service a client receives, (Evans, 2016).

The clinical history is a document that shows chronological medical attention. As Nurse

Practitioners we are legally obligated to document the treatment of all patients being

examined. This protects both the patient and the nurse practitioner and offers proof of the

services provided for payment.

The most important role of the clinical record is to assure that the high quality patient care

we provide is documented, must be complete, clear, legible, ordered chronologically;

contain the data of the patient, his ailment and the treatment. As a Nurse Practitioner we

should recognize that the documentation of our nursing decisions and actions is equally as

valuable, professionally and legally, as the direct care provided to patients. Quality

documentation is an important element of nursing practice, essential to positive client

outcomes and a key component of meeting their Standards of Practice.

The clinical history has a double character: on the one hand, the most important, allows to

the intervening professionals to have all the patient's data, their disease, of the studies

carried out, treatments instituted, interventions performed, etc., in order to provide the best

medical assistance to the patient. Without it, your health care would be compromised. A

provider would not know what another provider was doing. However, there is another

aspect that cannot be neglected by providers, and is the nature of evidence of the first

magnitude in a possible trial for professional responsibility.

Standards of Care Neglecting to document important details of a patient's visit to a

provider’s office can have huge ramifications for providers at a later date. For example, if a

doctor or a nurse does not record that a patient is allergic to penicillin, and the health care

provider later injects the patient with penicillin, which causes a severe allergic reaction, the

provider may be accused of negligence. Other scenarios where providers fail to document

medical data carefully and correctly can lead to medical malpractice claims. The complete

clinical history is the best proof that the provider counts to demonstrate the correct care

provided to the patient.

Medical billing and Coding without proper medical documentation, can not be reimbursed

by insurance. That means that if the health care provider forgets to write something in the

medical record regarding a treatment, surgery or procedure a client has received, the

provider will not be paid for it.

References

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Potter, P.A., Perry, A. G, Stockert, P.A. & Hall, A.M. (2017). Fundamentals of Nursing. St.

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Cutugno, C., Hozak, M., Fitzsimmons, D. L., & Ertogan, H. (2015). Documentation of

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