The act of recording patient information discovered in a complete health history is called documenting. The nurse establishes a trusting relationship with the patient to elicit exact and detailed information to build the foundation of an accurate health record.

The information gathered and documented is also used by the provider to diagnose and develop a plan of care based on current industry standards and best practice guidelines Once the nurse understands that the purpose of accurate documenting is to facilitate patient care among the healthcare team, then the nurse can identify what information to document.

health history — taken from each patient and updated regularly. health record — collection of subjective and clinical information pertaining to a patient’s physical and mental health, compiled from a variety of sources. information gathered and documented — also used by the provider to diagnose and develop a plan of care based on current industry standards and best practice guidelines. information — valid and reliable and then use professional clinical judgment on the observations and data collected.