Importance Of Nursing Documentation

Strategies of Nursing Documentation to Promote Patient Safety

Discussion

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as “anything which has been entered into a patient’s electronic health record or written in a patient record” (Perry, 2014, p. 47). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014, p. 47). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that, “As regulated health care professionals, nurses are

Timely Documentation

Avoiding delays in documenting is one of the best ways for nurses to accurately document. It is important for nurses to take the time to chart as soon as they are able. Kelly N. Kilgour recommends that charting should be completed, “midmorning, midday, and again within the last hour of your care shift” (Gregory, 2014 p. 545). Charting in a timely fashion is also important for interprofessional communication. Often there are many different health care providers involved with the care of a client. It is important that all other professionals are aware of what the client has received for care and what is still required. By documenting nursing actions other health care providers do not duplicate care. This is vital for patient safety as a duplicate of care, for example in medication administration could result in very serious even fatal consequences. Furthermore delaying documentation results in less detailed and sometimes less accurate reports as well. The College of Registered Nurses of British Columbia (CRNBC) states that delays in documentation can result in a foggy memory of patient care events and even omissions or errors in

The article Computerized versus Handwritten Records addressed a case study in the tragic death of Victoria Climbie and how illegible handwritten records in the Paediatric Intensive Care Unit (PICU) lead to her death (Whyte, 2005). It seems very basic for nurses to have legible handwriting, however in the busy heath care culture it is often overlooked. When nurses are unable to easily decipher a care provider’s order or patients record they are required to contact the individual who made the order or report for clarification (Perry, 2014). Nurses should avoid fatigue where their handwritten has become sloppy or their spelling compromised. Using appropriate abbreviations alleviates writing fatigue but should be used with caution to ensure that the meaning is clearly understood. Handwritten entries into patient’s records should always begin with the time and end with the nurse’s signature and title, “This guideline ensures that correct sequence of events is recorded; signature documents who is accountable for care delivered.” (Perry, 2014, p. 51). Moreover many health care settings are incorporating electronic record keeping which will replace some of the handwritten documentation and enhance safety (Procter,