Nursing documentation includes assessments, vital signs, medication administration, interventions, patient statements, and communications with physicians. Standards require contemporaneous and complete recording.
It is typically the highest-volume documentation in a chart.
Alternative Names:
Nursing Records, Nursing Chart Entries
Why it Matters?
Documentation of physician notification is the entry that most often determines liability allocation, since a nurse who documented calling a physician with specific findings shifts responsibility while an absent entry leaves the nurse exposed. Those entries are the first place to look in any failure-to-escalate claim. Volume also makes nursing notes the best source for reconstructing the actual sequence of events.
Frequently Confused with
Related terms
Frequently asked questions
Which entries determine allocation?
Why review nursing notes first?
