Nursing documentation

Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal and professional requirements, and one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients.

The internationally accepted nursing process consists of five steps: assessment, nursing problem/diagnosis, goal, intervention and evaluation. Nursing process model provides the theoretical framework for nursing documentation. A nurse can follow this model to assess the clinical situation of a client and record a constructive document for nursing communication.

Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process. The following sections describe the concept, aim, possible structure and content of these nursing documents using the example of nursing documentation in Australian residential aged care homes.

An admission form is a fundamental record in nursing documentation. It documents a client's status, reasons why the client is being admitted to a residential aged care home, and the initial instructions for that client's care. The form is completed by a nurse when a client is admitted to a residential aged care home.

The admission form provides the basic information to establish foundations for further nursing assessment. It usually contains the general data about a client, such as name, gender, age, birth date, address, contact, identification information (ID) and some situational descriptions about marriage, work or other background information. Based on the different nursing care provider's requirements, this form may also record family history, past medical history, history of present illness, and allergies (see Figure 1).

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