Serves as guide for diagnosis, treatment, follow up and evaluation of services, indicate progress and continuity of care, help self evaluation of medical practice, protects them in case of legal issues, and may be used for teaching and research.

Provide with documentation of services rendered, i.e. shows health condition of the client, provide data essential for planning and evaluation of services for further improvement, and serve as a guide for professional growth.

Provide the management with statistical information necessary for decision in regard to utilization of resources, planning for administrative control and future references, help the supervisor evaluate the services rendered, teaching done and a person’s action and reactions.

No individual sheet is separated from the complete record unless, as with the doctor’s order sheet, it is kept in a special place where its safety is guarded.

The hospital administration usually has a procedure with which the head nurse should be familiar for handling legal matter of this kind. Patient has the right to insist that his record be confidential.

The two parts of the record for which the nursing service is universally wholly responsible are the vital sign, graphic sheet and nurses’ observation or nurses’ notes.

Follow the SMART model or similar when planning care. SMART means? Select/tick all that apply.

Describe objective measurements or observations about clients’ condition and response to health problems. Stress recent change, but do not use critical comment about clients’ behavior.

These reports involve communication of information about clients from the nurse on sending unit to the nurse on the receiving unit.

This report describes in concise what happened specifically objective terms, etc. The nurse does not interpret or attempt to explain the cause of acts happened.

This is a report compiled daily for the number of patients. Very often it is done at midnight and the norms are collected by the night supervisor.

These reports are the nurses' responsibilities for sending them to governmental authorities for registration within the specified time.

A written record concerning some observation about a person or about her work.

Information about clients and their care must be functional. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells.

A client record must be reliable. Information must be accurate so that health team members have confidence in it.

The information within a recorded entry or a report should be present, containing concise and thorough information about a client care or any event or happening taking place in the jurisdiction of manger.

Delays in recording or reporting can result in serious omissions and untimely delays for medical care or action legally, a late entry in a chart may be interpreted on negligence.

The nurse or nurse manager communicates information in a logical format or order. Health team members understand information better when it is given in the order in which it is occurred.

Nurses are legally and ethically obligated to keen information about client’s illnesses and treatments be kept.