What is the process of recording patient information and care provided called?

The process of recording patient information and the care provided is known as documentation. This is a crucial aspect of nursing and healthcare practice, as documentation serves multiple purposes. It creates a permanent record of the patient's medical history and current health status, promotes continuity of care among healthcare providers, and enhances communication within the healthcare team. Furthermore, thorough documentation is essential for legal reasons, ensuring that there is a comprehensive account of the care rendered and the decisions made regarding a patient's treatment.

In the context of healthcare, effective documentation involves accurately conveying information about the patient's condition, treatments administered, responses to interventions, and any changes in status. This process supports the delivery of high-quality care by enabling providers to review past notes and assessments when making future care decisions. Overall, documentation is vital for both improving patient outcomes and meeting regulatory requirements in healthcare settings.