Documentation in Nursing Practice

Documentation is a vital aspect of nursing practice. It involves entering data that requires the use of clear, concise and complete words in the client's record. This is also referred as charting. This chart can be accessed by the client, physical therapist and the pharmacist or other members of the health care team. The client's consent is needed before the chart can be seen by other persons like a relative. The client's chart is owned by the hospital or institution. Record keeping is an integral part of nursing practice. It is a tool of professional practice and one that should help the care process. Documentation helps to Improve the quality of nursing care and promote nursing professional standards. The guidelines to be followed by the nurses while documenting nursing care is mandatory.