The importance of good nursing documentation should not be underestimated. Despite the vast amount of information and guidance available to practitioners, nursing documentation continues to be poor.
It is the author’s experience that nurses do not appreciate the importance of keeping records up to date until something goes wrong and their documentation is subject to scrutiny, appraisal and criticism. Often, in the event of a complaint or legal proceedings the only evidence the nurse will have to defend their actions is the medical notes and records. A practitioner is unlikely to remember each and every patient encounter.
Although this article is written from a legal angle it should not be forgotten that the primary function of nursing records is to aid communication between healthcare professionals and a patient. The purpose of records is to provide a clear and precise account of the patient’s healthcare journey and reflect the practitioner’s assessment, planning and evaluation processes.
The Nursing and Midwifery Council (NMC) sets out a nurse’s obligation in the Code to keep clear and accurate records relevant to practice. This obligation is not limited to patient records but includes all records that are ‘relevant to your scope of practice’. 1