Why Is Clinical Documentation Important?
Most health care workers are required to write about their daily work with clients. Clinical documentation is important because it:
- Allows members of the health care team to communicate with each other so that they can work together to keep clients safe and healthy.
- Serves as legal evidence that you have performed your job as ordered.
- Provides a place to record changes in the client's care plan.
- Helps health care organizations meet the requirements for licensure and/or accreditation.
- Keeps a record of the services provided to each client so that your workplace may receive payment.
What Should You Include in Your Report?
Observations
Observations are the facts and events that you notice as you go about your daily work.
Daily Measurements
You may be ordered to record you client's:
- Vital signs.
- Weight.
- Intake and Output.
- Blood sugar level.
Safety Issues
This includes measures you took to ensure a client's safety and any concerns you have about possible safety hazards in the client's environment.
Client Statements & Complaints
- Document -- in their exact words -- any pertinent statements your clients make about how they are feeling. This may include statements about pain, appetite or emotions.
- Be sure to report complaints. (again, use the client's exact words.) Complaints help your workplace improve client care and/or fine new ways to meet a client's needs.
Unusual Events
Report anything out of the ordinary that happens while you are with a client. For example, be sure to document if a client refuses care or if the heat in the client's room doesn't work. (Notify your supervisor as soon as possible, too.)
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