Summary

In every healthcare setting, a health history is taken from each patient and updated regularly. The nurse establishes a trusting relationship with the patient to elicit exact and detailed information to build the foundation of an accurate health record. Often it is the nurse’s responsibility to determine whether the information is valid and reliable and then use professional clinical judgment on the observations and data collected. Application of legal and ethical considerations will guide clinical decision-making. The information gathered and documented is also used by the provider to diagnose and develop a plan of care based on current industry standards and best practice guidelines.

The act of recording patient information discovered in a complete health history is called documenting. Once the nurse understands that the purpose of accurate documenting is to facilitate patient care among the healthcare team, then the nurse can identify what information to document. Patient information can be categorized into subjective and objective data. It is important to remember each healthcare facility will have policies and procedures related to documentation expectations. Additionally, nurses need to master communicating assessment findings in a clear and precise manner to improve patient care outcomes.

The incorporation of informatics with an EHR has drastically improved our healthcare system. As you incorporate the capabilities of an EHR into your daily clinical practice, remember regulations such as meaningful use and privacy laws. Nurses are at the forefront of patient care and often the eyes and ears of when something is not being done correctly. Using knowledge about how and when to release or discuss patient health information will ensure positive patient outcomes.