Why Documentation Matters

Medical documentation is not just paperwork—it’s a legal record and a tool for ensuring continuity of care.

What to Document

• Patient Information: Name, age, medical history, and vital signs.
• Treatment Provided: What you did, when, and how the patient responded.
• Observations: Anything unusual, such as changes in patient condition.

Reporting

• Verbal Reports: Give clear, concise handoffs to hospital staff.
• Written Reports: Complete electronic or paper forms carefully and accurately.

Real-World Applications

Good documentation protects you legally and helps the next caregivers continue quality treatment.