Promoting accuracy, accountability, and professional excellence in nursing documentation
On October 19, 2025, the Cordillera Hospital of Divine Grace (CHDG) conducted an in-service training titled “Charting with Confidence: The Language of Nurses’ Notes” at the CHDG Conference Room from 8:00 a.m. to 12:00 p.m.
The seminar focused on enhancing nurses’ documentation skills to ensure accurate, objective, and legally sound patient records—an essential component of safe and effective nursing practice. The session guided participants in applying proper documentation techniques aligned with institutional policies, professional standards, and ethical responsibilities in healthcare settings.
Representing the University of the Cordilleras College of Nursing (UC CON) were Clinical Instructors Wilbur Comafay and Clea Tindowen, who actively participated in the training and shared best practices from the academe.
Strengthening Documentation Standards
The discussion emphasized that nurses’ notes are more than just a written record—they are an essential communication tool linking assessment, intervention, and evaluation. Key points included:
- The importance of clear, concise, and factual charting to reflect patient care accurately.
- Avoiding vague terms and ensuring entries are timely, complete, and signed appropriately.
- Upholding professional and ethical standards to protect both the patient and the healthcare provider.
- Recognizing how effective documentation contributes to teamwork, continuity of care, and legal accountability.
Through this activity, participants strengthened their ability to document patient information effectively, thereby improving the quality and safety of healthcare delivery.
UC CON’s Commitment to Continuous Professional Growth
UC CON continues to support and encourage faculty involvement in professional development activities that enhance teaching and clinical supervision. By staying updated on the latest standards in documentation and communication, faculty can better guide nursing students in applying accurate and reflective charting practices during clinical duties.
This participation aligns with UC CON’s vision of producing competent, compassionate, and ethical nurses who demonstrate accountability and excellence in all aspects of care.
Sustainable Development Goals (SDG) Alignment
SDG 3 – Good Health and Well-Being
- Target 3.8: Achieve universal access to quality essential health services.
Accurate documentation enhances patient safety, quality of care, and continuity across health teams. - Target 3.C: Increase health workforce capacity through education and training.
In-service training directly improves nurses’ professional competence and practice readiness.
SDG 4 – Quality Education
- Target 4.4: Increase the number of youth and adults with relevant skills for employment and lifelong learning.
Develops advanced communication and record-keeping skills vital in professional nursing practice. - Target 4.7: Promote education that fosters responsible and ethical professional practice.
Reinforces integrity, accountability, and ethical documentation in nursing education and practice.
SDG 17 – Partnerships for the Goals
- Target 17.16: Strengthen multi-stakeholder partnerships for knowledge sharing.
The collaboration between CHDG and UC CON promotes continuous learning and best-practice sharing. - Target 17.17: Encourage effective public, private, and institutional partnerships.
Joint training activities enhance cooperation between hospitals and academic institutions in advancing nursing quality.
