Record keeping and documentation in nursing practise are 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 completely follow the nursing process (assessment, diagnosis, planning, implementation and evaluation) 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 a proof and verification to 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).
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
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