ABSTRACT
The fact that activities relating to nursing care need to be documented is nothing new. From the time that Florence Nightingale brought order and science to the nursing profession, there have been written records. What has changed, however, is the method and means of documenting, evolving from the simple paper and a pen to the sophistication of computer-based systems. The content of the documentation has also evolved with much of it now mandated by regulatory agencies, third-party payers, and government agencies as well as the legal aspect of the record, which is summarized in the adage surrounding malpractice lawsuits that admonishes: “If it wasn’t documented, it wasn’t done.”
