Importance of Charting
Documentation is an essential part of the nursing career as stipulated in the nursing code of professional conduct. Nurses are subject to scrutiny by professional bodies such as Human rights and Data protection acts, and proper documentation helps save nurses from contradicting situations when the time arises (Wood, 2015). It is essential therefore that record keeping in nursing be kept official to avoid future problems. For the nurse who says she doesn’t have to record everything, I advise that she starts to take charting seriously if she wants to keep her job professionally.
The code of professional conduct advises that proper documentation is a vital tool for communication among healthcare professionals especially nurses. The information documented is used as a reference for continued patient care in the wards and the outpatient departments. If the previous information is not available, care delivery is compromised, and wrong actions in treatment may be taken by the doctors and nurses. There is a common saying in the field of medicine “if you did not document, it didn’t happen.” It becomes difficult to account for necessary procedures in the hospital such as medication if charting was not done correctly (Wood, 2015).
The legal perspective in nursing is taken seriously when something goes wrong in patient care. Litigation and legal action are regarded as an occupational hazard in the field of medicine, and it is estimated that one in three medical professionals will be involved in the legal action at some point in their profession (Potter et al. 2015). During legal proceedings, documentation is used as evidence and as a defense for the allegations posed to the nurse. Therefore, the nurse has a legal and professional duty to keep proper records for effective communication, efficiency and consistency in patient care.
Wood, C. (2015). The importance of good record-keeping for nurses. Nursing times, 99(2), 26-27. Retrieved from https://www.nursingtimes.net/roles/practice-nurses/the-importance-of-good-record-keeping-for-nurses/205784.article
Potter, P. A., Perry, A. G., Stockert, P. A., & In Hall, A. (2015). Essentials for nursing practice.