Nursing documentation
Topic: Management
Recording assessments, interventions and client responses accurately, objectively, promptly and legibly. Documentation underpins team communication, continuity of care and legal protection: if it was not documented, it was not done. Record observed findings rather than personal opinions, use only approved abbreviations, and never erase an error; draw a single line through it, correct it and sign.
- Also known as:
- Charting, Documentation
- In Turkish:
- Hemşirelik kayıtları
What does Nursing documentation mean?
Nursing documentation is part of the Management topic in nursing. Students meet it in class, on clinical placements and while preparing for exams.
Search the whole glossary, add terms to your sets and review them in the Finito Nursing app.