Documentation comprises a vital aspect of nursing practice that not only chronicles the ongoing condition of a patient and his or her response to treatment, but simultaneously affirms that appropriate nursing interventions and care were provided. It serves as a record of the events that transpired, the medical approach that was elected, and the patient’s response to the care. Legally, if a task goes undocumented, it was not performed. Therefore, it is imperative that nurses understand and observe careful and meticulous documentation, as it is through such documentation that potentially devastating consequences and legal risks are mitigated.
