Nursing documentation is an integral part of nursing practice that promotes high quality patient care, continuity of care, and communication between healthcare providers. It provides an accurate account of a patient's treatment, care plans, and the care delivered. Nursing records are read by nurses, patients, relatives, doctors, and other healthcare team members. Registered nurses are professionally accountable for ensuring complete, factual, consistent, and clear documentation that demonstrates their assessment, care planning, actions taken, and arrangements made for patients. Nursing documentation can be used in legal matters and audits help assess record standards and identify areas for improvement.

1. Nursing Documentation

2. Why is there a need for nursing
documentation?
“ Record keeping is an integral part of nursing
and practice. It is a tool of professional
practice and one that should help the care
process. It is not separate from this process
and it is not an optional extra to be fitted in if
circumstances allow.”

3. Good record keeping promotes:
 High standards of clinical care
 Continuity of care
 Better communication & dissemination of
information between members of the health
care team
 An accurate account of treatment, care
planning and delivery of care
 The ability to detect problems at an early
stage

4. Who reads nursing records?
 Nurses
 Patients
 Relatives
 Doctors
 Members of the health care team

5. What is expected of a registered
nurse?
 The quality of your record keeping is a
reflection of the standard of your professional
practice.
 Good record keeping is a mark of a skilled
and safe practitioner.

6. Record keeping should demonstrate:
 A full account of your assessment and the care you
have planned and provided
 Relevant information about the condition of the
patient at any given time and the measures you have
taken to respond to their needs
 Evidence that you have understood and honoured
your duty of care
continued

7. Record keeping should demonstrate:
 That you have taken all reasonable steps to
care for the patient and any action or
omission on your part have not compromised
their safety
 A record of arrangements you have made for
the continuing care for the patient

8. Nurses accountability:
 Nurses are professionally accountable for
ensuring that any duties they delegate to
members of the health care team
 If a student nurse completes nursing records,
then a registered nurse must countersign the
entry, which shows that they agree with the
content.

9. Records should be-
 Factual, consistent and accurate
 Written as soon as possible after an event has occurred, providing
current information on the care & condition of the patient
 Written clearly in such a manner that the text can not be erased
 Written so that any alterations or additions are dated, timed and
signed in such a way that the original entry can still be clearly read
 Accurately dated, times and signed with the signature printed
alongside the first entry
 Not include abbreviations, jargon, meaningless phrases, irrelevant
speculation or offensive subjective statements
 Written wherever possible with the involvement of the patient or
carer and in terms that the patient can understand
 Readable on photocopies

10. Legal Matters of Nursing Record's:
 Nursing records can be used :
– in court of law by the Health Service
Commissioner
– To investigate a patient complaint
– In case of complaint of professional misconduct
“The approach to record keeping that the
courts of law tends to adopt is that if it is
not recorded, it has not been done”

11. Nursing Documentation
 The Nursing Process – a systematic
approach to nursing which comprises a
series of steps which, most commonly, are
referred to as assessing, planning,
implementing and evaluating.
Roper 1990

12. Audits
 By auditing records – We can assess the
standards of records and identify areas for
improvement and staff development