Provide complete medication administration documentation and patient response. Record details of phone calls or messages to provider and response; include date and time. Document preventative …

The American Nursing Association (2010) states, “Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice.”

Clinical documentation: Any manual or electronic notation (or recording) made by a provider or other healthcare clinician related to a patient’s medical condition or treatment

Good Documentation Practices, commonly referred to as GDPs, are the guidelines that one follows in recording information in a legible, traceable and reproducible manner.

Documentation is how we give credit to others for their contributions to our work. We must document the ideas, theories, definitions, data, images, and other information in our writing that originated with others.

Practitioners should consult with their payer source for specific documentation requirements and refer to their state practice act when documenting OTA supervision.

ANA’s Principles for Nursing Documentation identifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings.