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Data Reporting and Recording01:24

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...
Legal Guidelines for Documentation01:06

Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Types of Records II: Educational and Administrative Records01:18

Types of Records II: Educational and Administrative Records

Maintaining nurses' educational and administrative records in healthcare settings, including hospitals and nursing schools, is paramount. Here's a breakdown of the types of academic records mentioned:

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Updated: Jun 4, 2026

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
09:00

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

Documentation and record keeping.

Susan Pirie1

  • 1Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill RH1 5RH. spirie2000@yahoo.co.uk

Journal of Perioperative Practice
|February 17, 2011
PubMed
Summary
This summary is machine-generated.

Accurate healthcare documentation is vital for patient safety and resolving incidents. This article examines common record-keeping errors affecting the use of electronic health record systems.

Related Experiment Videos

Last Updated: Jun 4, 2026

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
09:00

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

Area of Science:

  • Healthcare Administration
  • Medical Informatics
  • Patient Safety

Background:

  • Documentation is crucial in healthcare, particularly in perioperative settings.
  • Accurate records enhance perioperative practice and aid in resolving legal/professional incidents.
  • National guidelines emphasize meticulous record-keeping for patient safety.

Purpose of the Study:

  • To identify and discuss common record-keeping errors.
  • To analyze the impact of these errors on practitioners' understanding of electronic record systems.

Main Methods:

  • Literature review of national guidelines and common documentation errors.
  • Analysis of potential misconceptions arising from record-keeping inaccuracies in electronic systems.

Main Results:

  • Several common documentation errors can negatively impact perioperative practice.
  • These errors may lead to practitioner misconceptions regarding electronic record system functionality and data integrity.

Conclusions:

  • Addressing common record-keeping errors is essential for effective use of electronic health records.
  • Improving documentation practices can enhance patient safety and practitioner confidence in digital systems.