Nursing documentation is responsible for keeping the legal record of the patient, which is known as the patient’s chart, regarding his personal information and care. On the other hand, nursing reporting occurs when two medical professionals directly and indirectly involved in the care of the patient collaborate and exchange information about the care of the patient, either by personal or telephone conversation. What are the functions of the patient’s chart? 1. Communication It serves as a well-organized process of relaying necessary information from one care provider to another. It imparts important data about the patient’s condition. 2. Legal Documentation It will serve as legitimate evidence used even in court. 3. Research Health information provided which can be basis for ongoing and future research 4. Statistics It can be used as a statistical data for health-related planning 5. Education Health science students can utilize the facts for educational purposes 6. Review and Quality Assurance The record can be utilized to assess the healthcare quality provided to the patient and the competency of the healthcare provider. 7. Preparation of Patient’s Care The chart can be the source of information for the whole healthcare team to plan the patient’s care. Good Features of […]
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