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Abstract
Documentation is one of the most important functions performed by the nurse. The importance of documentation and reporting, and that accurate and complete records are required by law and must be kept by all agencies, governmental and non-governmental, is to be emphasized. To improve the quality of care, reporting system must become more comprehensive, standardized, and widely available. Documentation may be broken into three parts, namely data collection, analysis and planning, and evaluation. Data collection is defined as the information collected as the result of measurement, and includes clinical data such as vital signs, homodynamic values, or lab results. It also can include data such as the number of staff members attending a fire safety class. Data collection is best handled on charts and graph. Planning involves a written record of the intent to act and directs the actions to be taken. Evaluation is accomplished by keeping progress records. By sharing information through records, nurses would improve the standard and continuity of care. This study was conducted in order to achieve quality nursing documentation through application of a self-learning package for nurses working in Menoufiya University hospital. This was achieved through assessment of knowledge, criteria and standards, and comments for nursing documentation, designing and implementing a self-learning package for and evaluating the effect of application of this self- learning package on the quality of nursing care.