Professional Documents
Culture Documents
account of pertinent client data, nursing clinical decisions and interventions, and the client’s
responses in a health record (Perry, Potter, Stockert & Hall 2017). Documentation is an
integral part of professional nursing and safe practice and is not optional. The basic purpose
Nursing documentation demonstrates what the nurse does for/with the client and is one part
of the broader inter-professional documentation that forms the client health record. The
provides evidence of the care, treatment or service a client receives, (Evans, 2016).
The clinical history is a document that shows chronological medical attention. As Nurse
Practitioners we are legally obligated to document the treatment of all patients being
examined. This protects both the patient and the nurse practitioner and offers proof of the
The most important role of the clinical record is to assure that the high quality patient care
contain the data of the patient, his ailment and the treatment. As a Nurse Practitioner we
should recognize that the documentation of our nursing decisions and actions is equally as
valuable, professionally and legally, as the direct care provided to patients. Quality
the intervening professionals to have all the patient's data, their disease, of the studies
carried out, treatments instituted, interventions performed, etc., in order to provide the best
medical assistance to the patient. Without it, your health care would be compromised. A
provider would not know what another provider was doing. However, there is another
aspect that cannot be neglected by providers, and is the nature of evidence of the first
provider’s office can have huge ramifications for providers at a later date. For example, if a
doctor or a nurse does not record that a patient is allergic to penicillin, and the health care
provider later injects the patient with penicillin, which causes a severe allergic reaction, the
provider may be accused of negligence. Other scenarios where providers fail to document
medical data carefully and correctly can lead to medical malpractice claims. The complete
clinical history is the best proof that the provider counts to demonstrate the correct care
Medical billing and Coding without proper medical documentation, can not be reimbursed
by insurance. That means that if the health care provider forgets to write something in the
medical record regarding a treatment, surgery or procedure a client has received, the
Akhu-Zaheya, L., Al-Maaitah, R., & Hani, S. B. (2017). Quality of nursing documentation:
Esper, P., & Walker, S. (2015). Improving documentation of quality measures in the
Evans, RS. Electronic Health Records: Then, Now, and in the Future. Yearb Med Inform.
PMC5297955.
Potter, P.A., Perry, A. G, Stockert, P.A. & Hall, A.M. (2017). Fundamentals of Nursing. St.
Cutugno, C., Hozak, M., Fitzsimmons, D. L., & Ertogan, H. (2015). Documentation of
Impact And the Health Record. Nursing Economic$, 33(4), 219–226. Retrieved
from https://search-ebscohost- com.links.franklin.edu/login.aspx?
direct=true&db=a9h&AN=108944038&site=eds- live.