Documentation Process in Professional Nursing

According to Charalambous and Goldberg (2016), professional nurses work in settings that require proper documentation for effective communication with other members within healthcare facilities. They prepare records that are utilized by doctors or other personnel providing care to patients or assistive workers whose primary role is to provide services that are not directly related to handling the sick. Across organizations, nurses maintain records that should be clear and accessible to support a safe nursing practice that is based on evidence. Clear records show how nursing professionals communicate with government bodies, researchers, and registration agencies. It is important to stress that when a nurse documents a patient’s information, he or she also adds doctors’ names to make sure the most appropriate professionals provide services to the client (Charalambous & Goldberg, 2016). In other words, including doctors’ names ensures that the right procedures and follow-ups are achieved when a nurse reports issues to the doctor.

Although the nursing documentation may occasionally be perceived as a form of distraction from the processes of patient care, it is an integral component of the profession across settings and duties. When a nurse intends to make the right assessment, for instance, he or she correctly collects and analyzes a client’s information that is used by doctors to arrive at the proper diagnosis (Charalambous & Goldberg, 2016). As stated by Charalambous and Goldberg (2016), it is important to note that accuracy during the initial stage of nursing greatly supports effective care during the other steps. Furthermore, for nurses to monitor the progress of their clients, they use progress notes that are designed and maintained in formats that can be easily understood by other personnel in care facilities as well as relatives of patients. Such progress notes aid doctors to assess the clinical status of a patient and make conclusions geared toward evidence-based care (Charalambous & Goldberg, 2016).


Charalambous, L., & Goldberg, S. (2016). ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care?. Journal of research in nursing, 21(8), 638-648.