On This Page
Documenting Assessments
I work at a long-term care home. I recently assessed my client and there are no changes to their assessment since the morning shift. I agree with the former nurse’s assessment. Can I just copy the assessment, or do I need to document my own assessment?
Documentation is an integral component of interprofessional communication within the client record. Each nurse is accountable for their own nursing practice and are required to make and keep records of their professional practice, including the assessment of clients. By documenting your own assessment, you are capturing the nursing care you provided, which may include one or all aspects of the nursing process, such as assessment, planning, intervention, and evaluation.
Clear and complete documentation demonstrates your commitment to providing safe, effective, and ethical care by showing accountability for your professional practice, the care the client receives, and transferring knowledge about the client’s health history and progress to those within the health care team.
