Nursing Documentation Goals and Principles

Documentation simply means written, printed, or recorded which is then used as a record or evidence to be used as it should be. In the world of health, especially nursing, documentation is divided into three, namely: Brevity, Legibility, and Accuracy.

According to Hidayat in one of his books, it is explained that nursing documentation is evidence of recording and reporting to record care that is useful for the needs of clients, health teams, or nurses themselves to be used in health services on the basis of written communication accurately and responsibly.

Meanwhile, according to the book written by Kozier and Erb entitled "Teaching Books on Nursing Fundamentals" explained about nursing documentation is a systematic method used to identify problems, plan, implement problem solving strategies, and evaluate the effectiveness of nursing actions

Purpose of Nursing Documentation

It takes a goal to do nursing documentation in the world of health carried out by nurses . Quoting from several experts, the purpose of nursing documentation includes:

  • As a means of communication between parties.
  • As a form of responsibility and accountability.
  • As information in statistics.
  • As a means of education.
  • As a collection of nursing research data.
  • As a guarantor of the quality of health services provided.
  • As a reference data in planning sustainable nursing care.
  • As legal and legal evidence for the nurse's responsibility to the client.
  • As a confidential document regarding client information.

Nursing Documentation Principles

The principle of professional accountability nursing documentation that can be accounted for, so that all aspects of the accuracy of a data must be concise ( breafity ) and easy to read (legality ).

The following are the principles of documentation in nursing:

  • Documents as an integral unit in the provision of nursing care.
  • In practice, nursing documentation must be consistent.
  • There is a format in nursing documentation.
  • The process of making documentation must be carried out and completed quickly.
  • Records in the documentation should be made chronologically.
  • In abbreviating a term, it is necessary to pay attention to the applicable guidelines.
  • The time, hour, date, signature and terms must be written.
  • Records in the documentation must be accurate, correct, complete, clear, practical, easy to read or written in ink.
  • Documentation actions are carried out by those who perform service actions or who observe directly on the client.
  • The nature of nursing documentation is confidential and stored securely.

Nursing Principles (Brivety, Legibility, and Accuracy)

According to Lynda Juall Carpenito, the principle of nursing documentation consists of three things, namely:

1. Brivety (Ringkas)

Nursing documentation should be made as concise as possible so that in writing it is not necessary to use words or sentences that are long-winded or unimportant.

This concise principle or brivety applies to all forms of nursing documentation, even though it is concise but must still have a clear and accurate meaning.

2. Legibility (readability)

The principle of nursing documentation must be easy to read and understand by all parties, especially care and other health workers involved in the documentation process.

The principle of legibility or legibility in nursing documentation must pay attention to foreign terms to be understood together.

3. Accuracy (Akurat)

Accuracy is needed in carrying out nursing documentation, because everything related to the client must be in accordance with the actual data or information.

Some data or information that must be accurate in nursing documentation regarding clients such as identity, lab results, physical examination data, and so on must be in accordance with the facts.

In addition, the most important record or documentation is in the matter of administering drugs by nurses to clients. Don't forget and write wrong





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