Accurate record keeping and careful documentation is an essential part of nursing practice. The Nursing and Midwifery Council states that ‘good record documentation helps to protect the welfare of patients and clients’ – which of course is a fundamental aim for nurses everywhere.
Registered nurses have a legal and professional duty of care. According to Nursing and Midwifery Council Guidelines, your record keeping and documentation should demonstrate:
-a full description of your assessment and the care planned and given
- relevant information about your patient or client at any given time and what you did in response to their needs.
-that you have understood and fulfilled your duty of care, that you have taken all reasonable steps to care for the patient or client and that any of your actions or things you failed to do have not compromised their safety in any way.
- a record of any arrangement that you have made for the continuing care of the patient or client.
I don’t think that us registered nurses can effectively document all this if we don’t possess the skill of academic writing.