OVERVIEW OF NURSING DOCUMENTATION

TUGAS INDIVIDU
Untuk memenuhi tugas matakuliah
Bahasa Inggris
Yang‌‌dibina‌‌oleh‌Bapak Yulius Irham, S.Pd.,MM 

Oleh:
Maharani Puspita (P17212215022)

KEMENTERIAN KESEHATAN
POLITEKNIK KESEHATAN KEMENKES MALANG
JURUSAN KEPERAWATAN
PROGRAM STUDI PENDIDIKAN PROFESI NERS
Agustus 2021
Questions:
1. Why do you have to make clear, accurate, and accessible documentation?
Because documentation is an essential element of safe, quality, evidence-
based nursing practice and Documentation of nurses’ work is critical as well for
effective communication with each other and with other disciplines
2. What is documentaion?
Documentation is an essential element of safe, quality, evidence- based nursing
practice. Nurses practice across settings at position levels from the bedside to the
administrative office.
3. Who are responsible and accountable for the nursing documentation that is used
throughout an organization.
The registered nurse (RN) and the advanced practice registered nurse (APRN) are
responsible and accountable for the nursing documentation
4. It 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. What does it
refer to?
Documentation of nurses’ work