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Florida International University Digital Commons Nicole Wertheim College of Nursing Student Projects Nicole Wertheim College of Nursing and Health Sciences1232021Nursing Documentation in an Inpatient
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Nursing documentation in an is a written record of a patient's care provided by nurses or other healthcare professionals.
Nurses and other healthcare professionals who provide care to patients are required to file nursing documentation.
Nursing documentation should be filled out accurately, completely, and in a timely manner following the organization's guidelines.
The purpose of nursing documentation is to provide an accurate account of the care provided to the patient, communicate with other healthcare professionals, and support legal and billing processes.
Information such as patient assessment, care provided, medications administered, patient response to treatment, and follow-up care instructions must be reported on nursing documentation.
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