Staff nurses are both care givers and authors of documents in medical records. The author discusses the process and context in which nursing documents are created and how they are actually used in delivering care. Archivists concerned with hospital recordkeeping systems should note that the medical record does not fully reflect nursing activities. A sociological study of nurses' recordkeeping practices suggests that nurses engage in two types of recordkeeping: administrative and clinical. Most documents produced through administrative recordkeeping become part of a patient's medical record, while most clinical recordkeeping documents do not. Nevertheless, it is the latter type of recordkeeping that nurses find most useful in their practice.

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