Medical documentation means recording all important information about a patient’s care — such as observations, treatments, and changes in condition — clearly, truthfully, and on time. Accurate records help nurses, doctors, and other caregivers make the right decisions for the patient’s safety and recovery.
Example:
If you help a patient eat breakfast and they refuse food, you should record it immediately. That small note might help the nurse understand why the patient feels weak later in the day. Every detail matters in patient care.
Live Case:
A nursing assistant in a hospital in Kenya forgot to document that a patient had vomited several times during the night. The morning nurse assumed the patient was fine and gave medication that worsened the condition. The incident taught the whole team the importance of accurate and timely documentation — it’s not just paperwork; it’s patient safety.
Apply it now:
Write clearly and correctly: use simple, professional language.
Record promptly: document care as soon as it is done — not hours later.
Be truthful: never guess or make up information.
Use proper forms or charts: follow your facility’s documentation procedures.
Protect privacy: keep records confidential and never share patient information with unauthorized people.
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