A Study to Assess the Importance of Nursing Documentation in a Tertiary Care Hospital

Jijo P Thomas, Poonam Lohana

Abstract: Nursing documentation is a legal record and a communication for continuity of care. This audit is aimed to examine the current practice of nursing care documentation and develop project for improvement. It is based on the fundamental concepts of assessment, planning, implementation and evaluation. A concurrent review method has been used to evaluate nursing documents. One nurses documentation per unit per day for two weeks is being assessed and analyzed from all units using the nursing clinical audit tool.

Keywords: Nursing Documentation