Legal Tips and Documentation in Nursing Implementation


LegalTips and Documentation in Nursing Implementation

Documentationis one of the important things in the health sector. Most nurses tendto ignore proper documentation (Williams, 2008). The professionals inthe area of health such as nursing ensure that they keep good recordsof their work. Good record keeping has a lot of significance since itbenefits both the professionals and the patients. One of theadvantages of good record keeping is that it helps in the safety ofthe patients since the doctors rely on the information that is alwaysdocumented. Nowadays, the health professionals in various hospitalsare required by law to ensure that they keep the records of thepatients regardless of whether they are admitted or discharged. Thedetails of the patients“ illnesses should be maintained safely forfuture reference. Documentation is one of the roles of nurses(Cheevakasemsook et al., 2006).

Thehealth sectors should come up with more rules that enhance the properand improved documentation. While documenting, the nurses should putthe interests of the patients at heart, and the material should bedone accurately and appropriately. The documents should give somedescriptions as per the observations. Assumptions should be avoidedaltogether during documentation. In addition, the documents should bewritten neatly to enhance faster reading by the interested people. Alot of care should be taken while writing a report. During writing,there should be uniformity in the flow of the contents. However, noideal additions should be made to the documents. Furthermore, quickconclusions should not be carried out before diagnosis. The nursesshould not blame anyone for anything in the documents since they arerequired to follow the reports from the laboratory. The nurses shouldhave some breaks at work (Nugent &amp Vitale, 2013).


Cheevakasemsook,A., Chapman, Y., Francis, K., &amp Davies, C. (2006). The study ofnursing documentation complexities. InternationalJournal of Nursing Practice, 12(6), 366-374.

Nugent,P., &amp Vitale, B. (2013). Fundamentalsof nursing: Content review plus practice questions.New York: F.A. Davis.

Williams,L. (2008). Completeguide to documentation.New York: Lippincott Williams &amp Wilkins.