NURSING DOCUMENTATION IN CLINICAL PRACTICE

It is widely accepted that if the care provided by the nurse is not documented then that care was not provided. Unfortunately, this saying has not been well implemented by nurses where you may find a nurse working for a period of 8 hours or more day and night shifts without documenting the care given to his/her patients including many activities related to that care (Feeding, sending patient to lab or radiology investigations etc.) and changes (Resuscitation e.g., CPR).

In many cases patient’s files lack nursing documents despite the nursing care provided from the point of patient admission to discharge. Thus, Nurses when required to give evidences of care provided to their patients/clients, they have no way to prove that such care was provided without showing the patient information that was properly documented

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