Documentation is a written or electronic legal record of all relevant patient data, including assessment, diagnosis, plans and interventions, and evaluation details.

A health record, or medical record, is a collection of medical information about an individual's health and medical history and contains information about the individual's past illnesses, medical procedures, medications, diagnostic tests, and notes from healthcare providers.

All health professionals who provide care add information to the health record to ensure continuity of care.

Reporting is the written or verbal communication of information regarding the patient's health condition, needs, treatments, outcomes, and responses.

Documentation and reporting are essential because they help healthcare professionals make appropriate decisions, maintain continuity of care, and work as a team.

Furthermore, documentation must adequately describe the patient's status and responses to interventions, particularly during admission, transfer, or discharge.

Documentation considers the current nursing practice standards and reduces the risk of errors.

The medical record is crucial evidence in lawsuits and can defend against claims of negligent practice by healthcare professionals.