Documentation, it is important in nursing. This is evident from Dion(2001)as cited in Owen (2005), where she states that accurate records not only ensures quality of practice but also safeguards the nurse by providing evidence of his or her professional ability. However in a study conducted by the Maryland Nursing Workforce Commission (2007) that nurses find documentation a waste of time. In this essay the writer will analyse the importance of nursing documentation in the current health care setting.
The importance of documentation
Documentation, a critical way of determining the standard of care rendered to a patient to defend nursing action(nurse together,2010).This agrees with the ANMCs competency standard 1.1 where it states that 'Practices in accordance with legislation affecting nursing practice and health care'. Documentation is defined as 'anything written or printed used to furnish evidence or information that is legal or official' (Crisp&Taylor,2001). With documentation, nurses are able to clearly describe the client's current health status and what interventions should be carried out and if the interventions that were carried out benefitted the client. This agrees with a citation from Owen(2005) where it says that documentation should provide factual, current, comprehensive and consistent information about the assessment and care of the patient.
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Documentation is important in nursing as it is a document by which healthcare team members communicate and contribute to a client's care (Crisp&Taylor,2001). The College of registered nurses, British Colombia(CRNBC,2007)supports this by stating that documentation communicates to other nurse and allied health workers their assessments about the status of clients, nursing interventions that are carried out and the results of these interventions. There are many forms of documentation. It is either oral, written, or based on the communication through the computers (Ioanna, et al, n.d.).Documentation is currently used for education, referrals and discharge planning in the health care setting. According to the Australian Nursing and Midwifery Council's (AMNC,2006) Code of Ethics' value statement 7, it states that 'This requires the information being recorded to be accurate non-judgmental and relevant to the health, care and treatment of a person'. Therefore accurate documentation is vital in the care of patients as it can be used against nurses when they breach their code of professional conduct. The CRNBC supports this by saying that the nurses documentation may be used as evidence in legal proceedings such as lawsuits, coroners' inquests, and disciplinary hearings through professional regulatory bodies.
Effective documentation provides a record demonstrating and giving proof of individualized nursing care and the patient's response to that care. It provides improved quality of care for the patient and accessible details in the event that a mistake occurs. It also helps to evaluate the performance of care and to see if the standards of care have been met (Henderson,2009).The patient record is a principal source of information in which the nursing documentation of patient care is an essential component(Bjorvell,2002).This can be supported by the AMNCs competency standard 6.3, where it states that 'Documents a plan of care to achieve expected outcome'( AMNC,2006).
Nurses document care as part of their professional responsibility(Iayer,2001).The ANMCs (2008) conduct statement 2,agress with the above stating that, nurses practice in accordance with the standards of the profession and broader health systems. To achieve the above the nurse has to relate safe and quality healthcare in the form of health documentation, information management and incident reporting (ANMC,2008).These documents help to facilitate care and coordinate for the treatment and evaluation of the patient's health status. It is also seen in Owen(2005) that even when there is no change in the patient's condition documentation should be carried out. This would help visiting practitioners who attend to the patient to be able to access information. Socialstyrelsen(2000) supports this statement as cited in Bjorvell(2002) where it mentions the emphasis on nursing documentation is because of the increasing need for secure and accurate transfer of patient- related information between different health workers.
Documentation- Errors and A Waste of time
'If you didn't chart it, you didn't do it' Iayer(2001) describes the phrase as an expression that puts fear into nurses. When incomplete documentation takes place this can affect a malpractice case. This is supported by Owen(2005) where she states that ' The approach adopted by the courts of law to documentation is that 'if it was not recorded it has not been done''. However there could be many reasons for incomplete documentation such as emergency situations when a patients needs take priority (Iayer,2001).This could later cause errors in documentation as the nurse might not have remembered what time certain events might have taken place. The ANMCs(2008) code of ethics value statement 7 supports this in it's explanation that 'all documentation is a record that cannot be changed or altered other than by the addition of further information'. Many Nurses in a study done by the Maryland Nursing workforce commission(2007) believed that too much time is spent on documentation when time could be spent on direct patient care. They also felt that certain documentation is often redundant. It also found that overtime of 1-2 hours was because of documentation (Maryland Nursing workforce commission,2007). Studies have supported this by showing that nurses spend from 25% of their time in the acute care setting documenting care rather than delivering care directly to patients (Krost,et al,2003,Epps-Reaid,2001) as cited in the Maryland study(2007).
In conclusion, we can see how important documentation is in the current health setting. It can be the standing evidence in the court of law when a nurse is subjected to a malpractice case as mentioned earlier by Iayer (2001). Documentation is also important as it helps with the communication between fellow health care workers to work together in improving patients' health status as mentioned by the CRNBC(2007). However even though at times it may seem to come out as a 'waste of time' as mentioned in the case study done by the Maryland Nursing work force commission(2007) or even as incomplete documentations(Owen,2005), it is important to keep in mind that documenting the right amount of information would benefit both the patient and the health care professionals. Therefore Documentation is and will continue to be important in the care of patients in the current health care setting
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