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Documentation for the Correctional Nurse

Documentation is one of the most critical skills nurses perform, regardless of the setting in which they practice. Accurate, detailed documentation provides a clinical picture of the patient and a chronological history of their health care. Nursing documentation enables effective continuity of care for the patient. It also provides legal protection for the nurse and their employer. Nursing documentation provides important information for Continuous Quality Improvement projects and audits and provides information about the care given at the facility to such accrediting bodies as the National Commission on Correctional Health Care and the American Correctional Association. The information documented today may be read in the future by many people, including other team members who care for the patient; accreditation, certification, and licensing organizations; performance improvement committee members; and lawyers and judges if the patient’s medical record becomes part of a legal action.  Thus, it is very important for correctional nurses to know the elements of documentation and to use them in their practice.