DOCUMENTATION AND REPORT WRITING.

 DOCUMENTATION AND REPORT WRITING. 

What is documentation?

Definition of Documentation:

Documentation is any written or electronically generated information about a client that describes the care or service to the client.

A report is a document characterized by information or other content reflective of inquiry or investigation, which is tailored to the context of a given situation and audience.

Reason for Documentation:

To facilitate communication:

Through documentation, nurses communicate to other nurses and care providers their assessments about the status of clients, and nursing interventions that are carried out. Documentation of this information increases the likelihood that the client will receive consistent and informed care or service. 

To promote good Nursing care

Documentation encourages nurses to assess client progress and determine which interventions are effective and ineffective, and identify and document changes to the plan of care as needed. 

To meet professional and legal standards: 

Documentation is a valuable method for demonstrating that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and judgment according to professional standards. The nurse’s documentation may be used as evidence in legal proceedings through professional regulatory bodies. E.g. in a court of law, the client’s health record serves as the legal record of the care or service provided. 

Report writing

Reports are accounts of events either written or verbal, heard or seen. Written reports are important because they provide records which serve as legal documents. One of the principles of report writing is accuracy and precise about what is reported. Report writing is an exercise that is closely associated with the nursing profession from time in memorial. Written reports provide records which are necessary in the nursing duties. The following are the types of written record:- 

⦁ Patients’ treatment files

⦁ Admission registers

⦁ Budget files

⦁ Stock cards for drugs etc