Nursing documentation in the electronic health record (EHR) is an important nursing function for several reasons, including facilitating communication within the care team, demonstrating evidence of clinical care, promoting health research, and capturing a legal record of patient care. Nursing Documentation: Proof of Excellence examines aspects of nursing documentation, including the importance of capturing the complexity of care, and creating a story of a patient encounter, and the RN’s role in informed consent and diagnostic accuracy.
