Nursing documentation is a major component in nursing care field.nursing care plan consist of 5 things-assessment,objective,planning,implementation,evaluation.quality nursing documentation plays a vital role in the delivery of nursing care services.documentation helps in better communication between the health team members.some advantages of nursing documentation are-
.it provides written record in clinical field.
It gives a evidence in the court.
It helps to keep the patients data confidential.
It helps to synchronize the data for quality assurance services.
After every nursing procedure documentation should be done. It helps to avoid Repeat of a nursing care.it gives a concrete handover to the care giver during shift changing.
For example- a caregiver is checking vital signs for a client at 6 am.so here she has to document it in a TPR sheet..after that she will give handover to the next shift person that TPR sheet.so this is the example of proper nursing documentation and it will affect patients outcomes.
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