• Generally, the purpose of clinical documentation is to facilitate communication and provide a record that standards of professional practice have been met.
• Inadequate, incomplete, or inappropriate communication is central in numerous malpractice claims, including communication failures related to delegating and supervising, shift reports, reporting appropriate information to other departments, unit-to-unit or agency-to-agency reporting, appropriate client discharge instructions, client teaching (e.g., medication administration, care of dressings), and reporting targeted information to doctors and other health care providers.

Effective Communication

• Effective communication is
• Simple: briefly and comprehensively relates data using commonly known and understood terms
• Clear: states exactly what is meant, covering the who, what, when, where, why, and how of the matter
• Pertinent: contains data that are important to the current situation and ties data to an apparent need to show significance
• Sensitive: considers receiver's readiness and adapts depth and breadth of data to meet receiver's needs
• Accurate: includes factual information related with confidence and credibility
• Interdisciplinary communication is vital to maintain continuity of care.

Privacy

• Client privacy must be maintained in all settings and through all reasonable means, whether verbal or written. In addition to the ethical obligation of the nurse to maintain privacy, the client is protected through federal legislation under the Health Insurance Portability and Accountability Act. Violations of protection of the client's privacy could result in criminal or civil litigation. Verbal and written communication must be confined to the appropriate settings and only to appropriate individuals to facilitate client care. Neither students nor clinical staff or others not involved with the client's care should access the client's record.
• All conversations about the client should take place in a private setting away from uninvolved parties and should be kept confidential. If a tape or other recording of client information is made, the recording should remain on the nursing unit in the designated place or at the service agency.
• All electronic communication should take place over secure, private channels. Minimal personal client information should be provided over cellular phones, hand-held talking devices, or other open channels.

Verbal Communication

• Verbal communication involves a sender, a receiver, a message, and the environment in which the interaction takes place.
• Verbal communication includes the attitude projected—gestures, voice tone, rhythm, volume, and pitch—in addition to words spoken.
• Building effective communication skills requires a constant awareness of oneself as a sender and a receiver of messages.
• Communication approaches should be modified to meet the individual needs of the client (e.g., cultural, agerelated, religious orientation).
• Consider the following factors in the communication process: knowledge level; personal perceptions, values, and beliefs; language; environmental setting; roles in the family and interpersonal relationships; space; and the general status of the client's health.
• Often, patterns of client behavior warrant the use of special approaches for client communication. Clients who are anxious, depressed, in denial, angry, and potentially violent present additional considerations for effective communication.
• The home setting may provide unique challenges to verbal communication. Efforts should be made to minimize distractions and to include all family members in communication, as appropriate.

Written Communication

• Written communication refers to electronically generated or manually written information or documentation and involves the process of providing clear descriptions and documentation of client assessment and needs, client care activities, and nursing process activities directed toward meeting the client's needs.
• Electronic/written communication is often the major and occasionally the only medium for data exchange among health care team members.
• Communication that is client-oriented and reflects the nursing process is more focused and organized than disjointed, task-oriented communication.
• Written communication often provides proof of practice or malpractice. Legally speaking, if something is not documented, it did not occur. Overall, documentation should reflect that standards of care were upheld. Focus charting or charting by exception may be used to minimize lengthy narrative charting through the use of checklists. Clear documentation is the best proof that responsible, well-planned nursing care was provided.
• Documentation of client progress (often nurses' progress notes) and care activities and plans of care often will be the only proof in future years that clients were monitored and cared for. Documentation should be proactive, reflecting that standards of care in nursing practice have been met.
• Well-written plans of care, completed flow sheets, clearly documented medication and treatment records, and progress notes provide a strong foundation for continuity of client care.
• Standardized plans of care may be used in some settings; however, individualization of the plan of care should be possible, and basic knowledge of the plan of care preparation remains beneficial.
• The terms goals, outcomes, and objectivesare often used interchangeably; however, distinctions are made between the terms in some settings. Nurses should be familiar with the use of these terms in the setting in which they work. The emphasis is on assuring that there are clearly identified indicators of the client's progress related to a specific nursing diagnosis or identified problem.
• Client outcome or critical path timeline plans may guide patient care. Documentation of client outcomes remains important for evaluation.
• Although nursing diagnoses accepted by the North American Nursing Diagnosis Association are available as a reference, additional clinically useful diagnoses such as collaborative problems may be used if accepted by the institution.