What does documentation in nursing entail?

Documentation in nursing primarily involves accurately recording patient information and care outcomes. This process is essential for several reasons: it ensures continuity of care, provides a legal record of the patient's status and treatment, and facilitates communication among healthcare team members. Accurate documentation helps trace the patient's progress, informs necessary adjustments in care plans, and supports quality improvement initiatives.

The practice of recording in a structured manner not only aids in patient safety but also complies with legal and regulatory requirements in healthcare settings. By providing clear and detailed notes, nurses contribute to a comprehensive understanding of the patient's needs, thus enhancing the overall quality of care delivered.