Problem
Documentation is anything written or printed relating to the patient. Documentation constitutes a fundamental tenant of nursing care and a legal responsibility. The information nurses communicate regarding their patients' care reflects the quality of care and accountability for care provided.
• Discuss one legal guideline for electronic and one legal guideline for written documentation.
• It is imperative to remember that nurses need to follow basic principles to maintain confidentiality during the transmittal of patient information via verbal, written, or electronic media formats.
• Discuss four ways to maintain confidentiality of electronic and written records.