Reasons for Documentation – Documentation in Nursing: 1st Canadian edition

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• Why documentation is so important

• a legal obligation to document

• the use of bedrails and assistive devices

• Documentation of medication administration is important in client safety, as it prevents the likelihood of duplicate administration

• For example, a quality improvement study could reveal high rates of incident reports related to falls, which could prompt in-service or training sessions surrounding the prevention of falls

• There is also a saying: “if it’s not documented, it wasn’t done” – your documentation notes must be complete, or it will be presumed that care was not provided.

• For example, influenza-related hospital admission rates and mortality rates are recorded and tracked each year

• Documentation is critically important in cases that involve violence because the client record may be used as a source of evidence in legal proceedings

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