What is Documentation?

All health professionals have a role in recording in patient case notes. The extent or the limit of this will vary according to the role you have in delivering patient care.

Documentation in patient case notes is one of the most common activities carried out by clinicians. When we say documentation, what we mean is recording any patient information by any means, whether that be paper and pen, electronically, or whether it be including photography and video recordings.

When we say documentation, what we're referring to is patient health records or patient case notes, as well as any other material including paper and electronic records, discharge forms and letters, risk forms, consent forms, communication books that you may have, as well as referrals to other organisations or other practitioners.

Primarily documentation is a method of communication between health professionals about the care provided and the patient's response to that care. That's why documentation is so important.

Documentation standards have developed from findings in courts and tribunals through the evolution of what is good practice rather than having any common law or legislation around documentation. Documentation can also reveal your standard in healthcare delivery.