Published Paper Details:

BACKGROUND: Nurses engage in various activities from the time of a patient's admission to his or her discharge from the hospital, helping patients to meet their needs that also include the recording and reporting. Each of the activities done by the nurses and the condition of the patient should be documented properly as authentic and crucial evidence. Current health care system required that documentation ensures continuity of care, furnishes legal evidence of the process of care and supports evaluation of quality of patient care. National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation and other allied programs for healthcare organizations. The mission of NABH is to operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety and quality of healthcare by adopting various national and international best practices. NABH is an Institutional Member as well as a Board member of the International Society for Quality in Health Care (ISQua) and on the board of the Asian Society for Quality in Healthcare (ASQua). Patient safety can be evaluated by mapping adverse events that occur in healthcare units. Studies done by Panesar et al. in 2015 have shown that 1-24 adverse incidents occur during every 100 consultations in the primary care context. A link between patient safety and inadequate documentation has previously been reported by studies examining documentation and adverse events in primary care. Andersson et al. in 2018, examined serious adverse events reports submitted by nurses in Swedish nursing homes to the Health and Social Care Inspectorate and found that a "lack of competence" and "incomplete or lack of documentation" were the two most common factors that contributed to adverse events.