Documentation: The Process and Legal and Administrative Considerations

Course overview

Charting, the recording and documentation of a patient's condition, treatment and response to treatment, is one of the most basic nursing skills. But its importance to both the patient and the nurse providing care cannot be overstated. This is because charting fulfills three important functions: first, it provides information about the patient's current condition, treatment response, and progress. Second, it serves as a legal record of the care provided. Third, it provides information used for reimbursement by third party payers.