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Authors

  1. Wong, Frankie W.H. MHS, BN, RN, CNN(C)

Abstract

Nursing documentation is an essential component for professional practice and providing quality patient care. A complete, accurate, and up-to-date document is a defense tool to prevent liability if nurses are involved in a lawsuit. To evaluate the quality of nursing documentation in a neurosciences unit, a chart audit project was conducted in year 2004. This project assessed nurses' documentation skills and consistency between prescribed care and care provided to patients. Strategies have now been implemented to improve nursing documentation and resolve issues that were identified during the chart audit.