What are the types of nursing documentation?

The most common types of nursing documentation include the following:

• Nursing Progress Notes.
• Narrative Nursing Notes.
• Problem-Oriented Nursing Notes.
• Charting By Exception Nursing Notes.
• Nursing Admission Assessment.
• Nursing Care Plans.
• Graphic Sheets.
• Medication Administration Records (MARs)

What is the importance of documentation in nursing?

Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice.

Why is documentation so important in the RCH?

Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistent clinical communication processes across the RCH.

Where are Ana’s principles for nursing documentation located?

ANA’s Principles for Nursing Documentationidentifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings. American Nurses Association 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492 1-800-274-4ANA www.Nursingworld.org

What happens if your nursing documentation is incomplete?

No matter how skilled or experienced you are, inaccurate or incomplete nursing documentation can mean serious trouble for your patients—and for you if you’re ever involved in a lawsuit. This article provides practical guidelines to help you document your assessments and interventions completely, accurately, and concisely.