The article emphasizes the importance of documenting the care that is given to the patient, since it is only by documenting that one can tell that the care was given, and how it was given. Accordingly, the charting and documentation should include everything done to the patient and at all the times. Such activities done to the patient and should be documented and charted include discharge planning and transfer, and well as the delivery of bedside care. The charting and documentation can be handwritten as nurse’s notes, flow sheets or can be done electronically.

In charting and documenting, one needs to be objective rather than subjective. In essence, one ought to chart what one has observed, felt, counted or measured, rather than what one has inferred or assumed. Documentation and charting should, however, not override the essence of providing care to the patients. Apart from charting and documenting the observations and changes a patient experiences, one ought to document what has been done to the patient. Documenting and charting for an activity that has not been done for the patient should be incorrect and subject to legal discipline. In addition, the documentation and charting is done after the activity has been completed.

It is highly encouraged that nurses chart for the care they have observed, in the case where they are required to co-sign. In such instances, the nurse ought to survey the information documented previously, before committing oneself. This is because charting and documenting makes one liable for the care that has been documented. One has to be sure that the care has been provided before committing to co-sign. In addition, the nurse is encouraged to chart the instances when a patient refuses the care, and the consequences of the refusal. When an error occurs in the documentation, a single line should be drawn against the error, and a correction made. One should also not accept t alter the documentation upon a colleague’s request. Finally, one should identify themselves after every entry is made.

Documenting the care is important in understanding one’s patient, their medications, changes, prognosis and progress. In regard to continuity of care, documentation allows all the members of the healthcare team to coordinate the care effectively, and know what was done for a particular patient, and what ought to be done for the patients. In this regard, nurses’ notes are very important because the rest of the members of the team rely on them in their provision of care. Additionally, documentation helps in the patient’s continuous assessment, since the healthcare team depends on the previously documented care to plan the way forward. As a step of the nursing process, it is crucial that every aspect of care to the patient be documented. Thus, charting and documentation completes the steps of the nursing process. In essence, charting and documentation enable the nurse to evaluate the care provided to the patient, and compare to the outcomes. This helps to plan the progression of care for that particular patient. Lastly, medical records are very useful for administrative purposes. The hospital administration uses the data to plan, and for research purposes. In addition, outside bodies like the government ministries and the insurance companies rely on the records in their compensation for patient care. in the cases where there is negligence or malpractices by the health team, the health records are very useful.