Introduction to Documentation: Health, Medicine, Nursing Essay

Introduction to Documentation
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Introduction to Documentation
Documentation is an essential concept in medicine, nursing, and any healthcare profession. Whether the documentation is done on paper, electronic or audio, the information should uphold the standards indicated in CNO (2008) such as confidentiality, accuracy, timely, and portray the physicians’ commitment to provide quality healthcare services. The documentation process is essential in monitoring their progress, recovery, re-infection, and communication with future healthcare providers. The documentation process is crucial because it reflects the patients' perspective, identifies the caregiver, and ensures continuity of healthcare by allowing other physicians to access the information (Alkouri, AlKhatib & Kawafhah, 2016). There will be efficient communication with other health practitioners on patient care plans, assessment, and necessary interventions that demonstrates the nurses' commitment to providing safe, ethical, and effective healthcare. After trying to document without using the CNO standards of documenting, I noticed my documenting skills correspond to the required standards.
First, my documentation was clear, accurate, and presented a comprehensive picture of the patients' needs, proposed interventions, and outcomes. I indicated the patients' assessment, intervention plans, patient's wishes, evaluation, prescriptions, and date of admission comprehensively, and sequentially (CNO, 2008). I also ensured that my patients' documentation was stored in a confidential file that could be accessed by the medical team and the patients only. I also ensured the information contained the name of the patient and mine for future reference and in case of any communication with caregivers in their next visit. Typically, my documentation was consistent, factual, accurate, easily accessible, neat, and comprehensive.
In the quest to ensure patients' wishes are upheld and known before and after their death, medical practitioners should document clear communication between the patient, family, substitute decision makers and other caregivers. Patients' wishes have fallen short b...