In nursing, patient records are important in effecting appropriate health care plan. Nursing documentation or records entails handwritten or electronic patient information that describes the health status of the patient and the care service to be provided to that patient (Plawecki, & Plawecki, 2007, p.3). Usually, nurses document health information pertaining to an individual patient. However, health records of group of patients such as therapy groups can also be kept. Documentation provides a clear picture of the health condition of the patient or group of patients, the expected actions of the caregiver and the evaluation of the patient(s) outcomes.
Nursing documentation is important for many reasons; firstly, it facilitates communication between nurses or care givers regarding the health status of the patient, the interventions undertaken, and the outcomes that result from these interventions. In chapter eight of his masterpiece book, “Legal and Ethical Issues in Nursing” Guido (2010) overemphasizes the need of proper communication in nursing practices (p.209), because nursing documentation prevents any likelihood of miscommunication and thus prevents medical errors. Secondly, documentation leads to improved nursing care provided to patients. Through documentation, nurses can evaluate patients’ progress, determine appropriate interventions, and plan for health care needs of the patient. In addition, documents or health records provide valuable information for nursing research, which leads to improvement in the quality of nursing practice and patient care. Thirdly, nursing documentation is important for meeting the professional and legal standards expected in any nursing practice (Plawecki, & Plawecki, 2007, p.4). Effective documentation provides evidence that a nurse acted professionally in his/her judgment and application of skills. In lawsuits, the patient health records provide evidence of health care service accorded to the patient relative to the professional care expected.