Description
Think about the principles of reporting and documentation. Identify and briefly discuss three challenges a nurse has in ensuring accurate and confidential documentation. Then discuss what actions a nurse can take to overcome these challenges including how informatics might make a difference.
Explanation & Answer
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Running head: DOCUMENTATION AND INFORMATICS
Documentation and Informatics
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DOCUMENTATION AND INFORMATICS
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Documentation is the communication concerning the patients’ care and can be printed,
hand written, or stored in computer and audiovisual systems. Therefore, documentation in
nursing is an essential and permanent part of medical records. Documentation is normally used
as a source of evidence for the accountability of every healthcare provider in their care delivery,
and nurses are thus supposed to document all the care they give to patients in all settings
(Mutshatshi et al. 2018). However, there are several challenges that are experienced by nur...