Clinical documentation relates to patient nursing care, as organizational and financial documentation is mostly for care organizations, management, policymakers, and health insurers.
FREMONT, CA: Clinical nursing documentation helps nurses reflect on their patient interventions and their outcomes. It ensures nursing care quality and continuity. Nursing documentation reflects the complete process of direct patient care. Clinical nursing documentation must include assessment, diagnosis, care planning, implementation, evaluation, and handover of care. Despite its necessity, nursing documentation can be time-consuming and burdensome for nurses. Nurses spend much time on documentation, even if it varies internationally. For instance, in Canada, nurses spend 26 percent of their time on paperwork; in Great Britain, 17 percent; and in the U.S., 25 percent–41 percent. In the Netherlands, nurses spend 10.5 hours weekly on paperwork, or 40 percent of their time.
Nurses' documentation time may vary by country due to electronic health records and handovers. Variation may also be due to confusion regarding what constitutes documentation. Some studies called tasks linked to patient care documentation, such as creating a care plan or writing progress updates. Documentation includes non-patient-care-related documentation such as tracking hours worked or staff planning data. In contrast, nurses might be more amenable to clinical recording since this documentation is necessary for high-quality nursing care. According to professional norms and guidelines, clinical documentation should be considered an intrinsic aspect of nursing care.
