Rapportage en registratie van gegevens

Recording and reporting are crucial in the documentation of data.

Recording is documenting data of an individual's health information that is traceable, secure, and permanent for communication.

In contrast, reporting refers to exchanging health care data in either oral or written form.

Accurate timing and proper documentation are the two vital components of reporting and recording.

All critical, factual data is recorded or stored permanently in an unerasable document or as data in an electronic system. This enables holistic care, as multiple providers have access to data recorded by any members of the patient's healthcare team.

Subjective data should be written in quotations; for example, patient reports a "squeezing, unbearable pain in my chest."

Specific terminology should be used to record and report objective data, such as sutures instead of stitches.

When entering data, do not generalize or analyze—instead, record precisely what the patient reports. 

Finally, the nurse's responsibility is to alert the interdisciplinary team whenever the assessment data significantly differs from the patient baseline, indicating a potentially serious problem.