Documentation is process of communicating in written form about essential facts for the maintenance of continuous history of events over a period of time. Recording and reporting are the other ways of documentation. Record is the permanent written communication that document information relevant to a clients health care management. Record means all documents facilities evaluation of the programme and provide continuity from the time the institution is established.

IMPORTANTS OF RECORDS AND REPORTS

Decision Making:

Records play an important role for making decision. Based upon the previous data, future planning, even decisions can be made.

Planning Client Care:

Records are very helpful for planning nursing care to the patients.

Communication:

Records and reports are very important for conveying the information to the employees, employer as well as to the public.

Legal Documentation:

Records are helpful for the legal purposes especially in medico-legal cases.

Education:

Records are helpful for teaching the nursing as well as medical students. Medical students learn from the previous records of the patients.

Research:

Records are the secondary source for data collection while conducting research, investigator did the recording of all the activities he/she performed during data collection.

Vital Statistics:

Records are used especially for assessing mortality and morbidity rate.

PRINCIPLES OF MAINTAINING RECORDS

1. There must be standards framed for record keeping that focuses on content quality.

2. Record should be for a specific purpose which should be clearly understood.

3. Records should contain only