Documentation and informatics

![CDATA[Clear and accurate documentation is vital as a communication tool for all members of the health care team, because it improves the person’s health outcomes and is an essential component of patient safety. It is important because all members of the health care team need access to the most up-to-date patient information so that appropriate decisions can be made about the person’s care and treatment (Gebru, Ahsberg & Willman, 2007). Patient documentation also acts as evidence if you or another member of the health care team is called to explain their care in a legal setting. Therefore, all documentation in the person’s health care record should be presented so that any reader has a clear and accurate description of the person’s journey from admission to discharge. This journey should highlight how a person’s condition improves or deteriorates, and how these changes are managed by all members of the health care team, (Jefferies, Johnson & Nicholls, 2011). To ensure that patient information is documented in a clear and accurate manner, many different systems of documentation have been developed in response to professional standards and competencies. Each system is designed to demonstrate the nurses’ and other health care professionals’ accountability for the care they give to their patients. The ability to communicate information clearly, reliably and accurately is vital to providing the safest care possible.]]