Name : Moch Agiel Devany Putro Mistoryanto

NIM : P17212235084

1. W h y d o y o u h a v e t o m a k e c l e a r , a c c u r a t e , a n d a c c es s i b l e d o c u m e n t a t i o n ?

Because clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based

nursing practice.

2 . W h a t i s d oc u m e n t a i on ?

Documentation is how nurses create a record of their services for use by payors, the legal system, government

agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with

health care. It also provides a basis for demonstrating and understanding nursing's contributions both to

patient care outcomes and to the viability and effectiveness of the organizations that provide and support

quality patient care.

3 . W h o a r e r e s p on s i b l e a n d a c c ou n t a b l e f o r t h e n u r s i n g d oc u m e n t a t i on t h a t i s u s e d t h r ou g h ou t a n or g a n i z a t i o n .

The registered nurse (RN) and the advanced practice registered nurse (APRN) are responsible and

accountable for the nursing documentation that is used throughout an organization.

4 . I t i s h o w n u r s e s c r ea t e a r ec o r d o f t h e i r s e r v i c es f o r u s e b y p a y o r s , t h e l e g a l s y s t e m , g o v e r n m e n t a g e n c i e s ,

a c c r e d i t i n g b o d i e s , r e s e a r c h e r s , a n d o t h er g r o u p s a n d i n d i v i d u a l s d i r e c t l y o r i n d i r ec t l y i n v o l v e d w i t h h ea l t h

c a r e.

W h a t d o e s i t r e f er t o ?

Nursing documentation