Documentation in Nursing Practice-Summary
Documentation in Nursing Practice-Summary
Record keeping and documentation in nursing practice is guided by, among other standards, legal standards stipulated in nursing practice acts and associated state laws. The legal standards require nurses to document based on established standards of care as well as on evidence-based practice (Arnold, 2012). In addition, nurses are required to follow the nursing process (assessment, diagnosis, planning, implementation, and evaluation) completely during documentation (Ferrell, 2011). Further, the legal standards require nurses to respect patients’ rights of confidentiality and privacy. A medical record should be accurate, systematic, logical and complete and should only be disclosed to persons involved in providing care, close relatives and friends and relevant persons where the patient is at risk of harm (Prideaux, 2012). Documentation provides legal protection for nurses in courts since it acts as proof and verification of patient care. A poor record is regarded by jurors as an indication of carelessness and failure to comply with established nursing legal standards. Thus, poor documentation makes it difficult for nurses to defend themselves in cases where they are accused of inappropriate practice (Dickerson, 2011). Finally, the legal standards of mandatory reporting require nurses to report an individual or occurrence when the public is at risk in order to facilitate the necessary action (Stricof, 2012).
References
Arnold, P., (2012). The importance of accurate documentation. Australian nursing journal, 19(10), p. 28
Dickerson, P. S., (2011). Reflective Documentation: Evidence of Quality. The Journal of Continuing
Education in Nursing, 42(12), p. 533
Ferrell, K. G., (2011). Documentation, Part 2: The Best Evidence of Care. The American Journal of
Nursing, 107(7), p. 61
Prideaux, A., (2012). Issues in nursing documentation and record-keeping practice. British Journal of
nursing (Mark Allen Publishing), 20(22), pp. 1450 – 1454
Stricof, R., (2012). Mandatory public reporting. Clinical Governance: An International Journal, 17(2),
pp. 109 – 112
Frequently Asked Questions (FAQs)
Why is documentation important in nursing practice?
Documentation is crucial in nursing practice as it provides a systematic, logical, and complete record of patient care, ensuring legal protection for nurses and confirming adherence to established standards of care.
What are the legal standards governing nursing documentation?
Nurses must document based on legal standards set by nursing practice acts and state laws, following the nursing process (assessment, diagnosis, planning, implementation, and evaluation) and ensuring patient confidentiality.
How does documentation protect nurses legally?
Accurate documentation serves as evidence in court, verifying the care provided and protecting nurses from allegations of negligence or inappropriate practice. Poor documentation can lead to legal consequences for nurses.
What should a nurse include in a medical record?
A medical record should be accurate, systematic, logical, and complete, and it should only be disclosed to persons involved in patient care, family members, or others when the patient is at risk of harm.