Documentation in health care

Abstract

Documentation in health care is the charting, recording and reporting of events which occurs during patients' hospitalization. It includes documenting admission, progress, responses to treaOUent and care, health education, discharge summary and incident reports. The record serves as a legal document of the care and treatment provided to the patient. Moreover it is a means of monitoring and evaluating staff performance of patient care and thus reflects the standard of practice. Good charting must be concise. accurate, complete, legible, timely and logically organised. Concise and precise patient documentation is significant in providing quality care and ensuring continuity of care across disciplines.