Appropriate and Accurate Documentation in Nursing

Subject: Health Care
Type: Argumentative Essay
Pages: 4
Word count: 959
Topics: Medical Ethics, Management, Nursing, Work Ethic

Table of Contents


The International Council of Nurses defines nursing as the autonomous as well as the collaborative care of people of all ages, families, groups, sick or well and in all settings. However, the council denotes that nursing encompasses the promotion of health, prevention of illness, care to the ill, disabled and the dying patients. For the activities of the nurses to be successful, they suggest that there should be the promotion of a safe surrounding, extensive medical research, and participation of all nurses in shaping the health policy. The society and the stakeholders in the health sector can assist in promoting an efficient health system by strengthening nursing’s influence, teaching policy courses and socialize the graduate students to do placements outside the nursing parameters. Nurses have the duty of sharing their knowledge with the rest of the nations and striving to be strong leaders to facilitate better healthcare in the world.

Documenting appropriately and accurately in nursing refers to any written or electronically generated information that gives a precise description of the status of the client or the care assigned to a particular client, and the data must be generated through the nursing process. The documentation must follow the following documenting principles that are the information must be factual, accurate, complete, current, organized, and compliant with the required standards. The use of abbreviations, symbols, and acronyms in nursing is only appropriate for use if every individual well understands their meaning. Abbreviations, as well as symbols that are obscure, obsolete, poorly defined or have various definitions, can lead to confusion and error in the administration of necessary health care services (Scota, 2012). In the assessment of a patient, nurses use both the subjective and objective data. The subjective data refers to the assessments that a nurse takes from the patient’s report. On the other hand, objective data refers to the information that is observable and measurable from the patient by the nurse. 

Clinical reasoning in nursing is the process through which nurses collect cues, processes the data, obtains an understanding of the patient’s problem, plans and implements intervention measures, evaluates the outcome, and reflects on and learn from the process. Clinical reasoning is best observed in the experienced nurses due to many encounters with different types of patients and problems (Levett-Jones, 2012). Through the clinical reasoning skill, a nurse can compile a comprehensive exam in an organization from past and current trends in the nursing practice. In the process of obtaining both the subjective and the objective information, it is important to group the findings into two categories. One of the partitions should contain all necessary normal assessment results from the patient while the other part contains abnormal findings from the patient. It assists in acquiring a list of reference that is knowing the urgent issue to deal with at first to the least fatal finding.

Proper assessment of the patients by the nurses should be the first objective to ensure the correct measures are implemented. Some of the factors that influence the assessment process both positive and negatively includes knowledge by the nurses, the attitude portrayed by the nurses during the nursing process, management of the organization, and the infrastructure, equipment, and allocation of necessary assessment resources to the nurses (Hagos, 2014). In the disposal of duties as a nurse, I pose different strengths in the field including being calm under pressure, respecting every individual, and having excellent communication skills. I believe that nurses have to be passionate in the line of duty for better service delivery and that good nurses are blessed through prayers from their patients.  Some of the values I have include being persistence at work and having the self-drive to learning more each day. These are some of the values needed for collecting comprehensive data, and they will help in having more accurate information on emerging issues in the healthcare department. 

Developing communication skills is essential to obtain adequate and correct information from patients. In the bid to improve the communication skills, I will use positive language, short and precise questions, and being respectful to every patient (Shamian, 2014). One of the primary interviewing techniques to use to obtain subjective data from the patient is using directive questions. Directive questions enable the patient to give correct information and or to provide supplementary information that may be useful. Some of the follow-up questions to use will include,

  1. How are you feeling today?
  2. Has the medicine improved your condition?
  3. What else can be done to make you more comfortable?

       Helping the patient accept his or her current situation will assist in administering medical interventions that will be suitable for the patient. Educating the patient, however, will be necessary to avoid a repeat of the same condition or making the situation worse. Using essential references from people who suffered from the problem and got well will ensure the patient has positive thoughts throughout the treatment process.


Nurses are vital in the administration of healthcare services in the world today, and they assist in unraveling essential information in the history of health. However, nurses must have excellent communication skills, passion, empathy, desire to learn more, and the ability to use clinical reasoning skills extensively. However, to ensure that nurses perform sufficiently, there must be a conducive environment, adequate tools for assessment, supportive management, and allocation of proper resources. The society and the stakeholders in the health fraternity have the sole responsibility of encouraging and supporting the work done by the nurses.

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  1. Hagos, F. (2014). Application of Nursing Process and Its Affecting Factors among, 1-9.
  2. Levett-Jones, T. (2012). CLINICAL REASONING , 1-6.
  3. Scota, C. o. (2012). Documentation Guidelines For Registered Nurses, 1-10.
  4. Shamian, J. (2014). The role of nursing in health care, 1-2.
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