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Lippincott Nursing Pocket Card - August 2022
Nursing documentation is a responsibility that spans all nursing practice levels and across all settings, from nursing assistive personnel, the registered nurse, and the advanced practice nurse. It is a crucial and fundamental skill that is necessary for clear communication among the interdisciplinary healthcare team members. Nursing documentation provides a full account of patient care to create a record of services for use by payors for reimbursement, helps to ensure quality patient care and reduce errors, is used by the legal system as evidence, generates data for research and quality improvement initiatives, and provides the basis for demonstrating nursing’s contributions to patient care outcomes (ANA, 2015; Goodwin, 2019).
The American Nurses Association (ANA) has identified six principles of nursing documentation to provide guidance for producing high quality documentation (ANA, 2015). These cornerstone principles will be highlighted below.
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