Nurses must maintain accurate and organized medical records for legal requirements, best practices, and to defend themselves against potential malpractice claims. Good record keeping involves documenting patient assessments, care plans, condition changes, responses to needs, and care arrangements. Records should be factual, objective, and avoid irrelevant statements. Maintaining accurate records has benefits like promoting better care, continuity, and protecting nurses' professional and legal standing if records are needed for hearings. Medical transcription services can help transcribe voice files into records accurately and efficiently.

1. Why Good Medical Record
Keeping Is important for Nurses
MTS Transcription Services

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Organized and up-to-date medical records are a hallmark feature of skilled and
efficient healthcare providers. However, sometimes allegations concerning shortcomings
of nurses occur and so it is important for nurses to maintain accurate medical records to
ensure best practices and also for legal requirements if any malpractice case arise. They
must make sure that the health records of the patients are accurate and include all
details regarding the services rendered. In health care units there may be a large
number of medical reports that need to be transcribed. Competent medical
transcription services can make the process of transcribing easier and quicker.
From a Legal Viewpoint
Litigation is considered as a major occupational hazard for medical staff, which has been
increasing rapidly. Accurate records are important at the time of hearing and their
absence makes it difficult for practitioners to prove that they have provided specific
services. Nurses’ records should ideally contain the following details.
 A full account of nurses’ assessment and care planned and provided for the
patients
 Relevant information about the condition of the patients at any point
 Measures the nurses had taken in response to the patient’s needs
 Evidence that the nurse understood and honoured the duty of care, and took all
the responsible steps to care for the patients and that any action or omission
has not compromised the patient’s safety
 A record of any arrangement the nurse has made for the continuing care of a
patient
Nurses should clearly note down the services they rendered. This is because they face
new issues and problems day to day and also due to the awareness of public rights and
increasing tendency to litigate. They must allocate time for both patient care and also for
documentation of the services provided. Good documentation can be a vital means of

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recollection of facts for nurses if and when they face litigation. Notes that are taken
down during their course of work are potential legal documents. These documents help
to maintain professional credibility.
When compiling records, the nurses should know that their colleagues rely on the
information they recorded when giving care to a patient. Colleagues should go through
nurses’ notes and ensure good care for the patients in a seamless continuum. If a nurse
is unable to return to work, the patient should not be ignored and must be provided
complete care. Nurses should ensure that if they delegate the record-keeping work to
someone else, they are supervised and also make sure that the substitute care providers
are capable of delivering their work effectively. All entries made in the patient chart
should be countersigned.
Tips to Improve Medical Record Keeping
The following tips will help nurses eliminate unwanted problems related to medical
record keeping.
 Use factual, consistent, accurate, objective and unambiguous patient information.
 Use quotation marks when required
 Use your senses to record what you did like I “felt”, “saw”, “ heard” etc
 Write up notes as soon as an event is over and make subsequent alteration if
required
 Ensure the records are accurately dated, timed and signed
 Mention if you have any objection about the care given
 Do not include meaningless phrases, irrelevant speculations and offensive
statements
 Notes should be made with proper understanding and involvement of the patients
or care giver

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Maintaining accurate and up-to-date records has immediate and long-term benefits for
both staff and patients. It also ensures that the professional and legal standing of nurses
are not undermined by absent or incomplete records, if they are called for any hearing.
Unambiguous and well-maintained medical records promote better communication as
well as consistency, continuity and efficiency and reinforce professionalism in nursing.
Transcribing voice recorded files into medical records is important and it can be done
with the help of a medical transcription company. These companies ensure
maximum accuracy in their work. They have skilled medical transcriptionists who can
provide quality and timely services at affordable rates. Partnering with a reliable
transcription firm is the best option to streamline large volume medical records and
maintain them safely.