“It helps us to communicate with other members of the health care team.”.

Nursing documentation is essential for clinical communication. Documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver individualised care.

Choice B is wrong because reimbursement is not the primary purpose of nursing documentation, although it may be a secondary benefit.

Choice C is wrong because legal liability is not the main reason for documenting care, although it may provide evidence in case of litigation.

Choice D is wrong because quality improvement is not the direct result of nursing documentation, although it may be facilitated by it.

Nursing documentation should follow six essential principles: documentation characteristics, education and training, policies and procedures, protection systems, documentation entries and standardized terminologies.

These principles help nurses to create clear, accurate and accessible records that can improve patient outcomes and safety.

: ANA’s Principles for Nursing Documentation - ANA Enterprise : Clinical Guidelines (Nursing) : Nursing Documentation Principles.