Recordkeeping in Nursing

1361 WordsJan 1, 20136 Pages
Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count…show more content…
Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007). Poor record-keeping can have serious implications for the patient and the nurse. Professionally, colleagues rely on the information recorded on a patient to maintain continuity of care (Wood 2003). The patient’s progress could rapidly deteriorate due to poor record-keeping, holding the nurse responsible and accountable for the patient’s decline in condition. Poor record-keeping in this instance could include a nurse not documenting a nursing intervention such as administration of a medication. If this is not recorded another nurse could easily believe the patient did not get the medication and administer it again, causing overdose and possibly have severe implications for the patient depending on the medication. Another example could be if the nurse noticed the patient’s condition worsening but did not document it. Consequently the patient may get significantly worse before it is detected by the next nurse on duty. In these instances the nurse responsible for the poor record-keeping will most likely be brought to the Fitness to Practice Inquiry and as a result may lose his/her registration as a practicing nurse. If the nurse has made a grievous error a patient or family member could take civil action.
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