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Abstract Nursing documentation is an important source of information for patient care and it is essential to apply accreditation standards in the field of documentation to have complete medical records. However, monitoring the implementation of standards and their fulfillment depend on a great number of standards such as communication standard, accountability and liability standard, and information Staff NyrsesSsecurity standards. Also manual of JCAHO for accreditation include initial patient assessment and reassessments, nursing diagnosis, nursing planning, nursing interventions, nursing evaluation and patient discharge summary. |