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Importance Of Record Keeping In Nursing

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Record Keeping is a vital part of nursing practice. It is essential for the accurate and effective care of patients. It includes the legal documentation which is needed for patient care.

(Cambridge Dictionaries Online 2014) states that Record-Keeping is the activity of organising and storing all the documents and files.
According to Youngson (1999) Nursing is the application of medical and humanitarian principles, by a person ancillary to the medical profession, so as to maintain health and fitness, assist in recovery from mental or physical illness or injury, relieve pain or distress or ease the process of dying.

(All Nurses 2014) states that the medical record is a permanent collection of legal documents that should have an accurate report concerning a patient 's health condition. Physicians, nurses, and other members of the multi-disciplinary team contribute to each patient 's medical record to reveal a patients current status, past history, any care that has been accomplished and any problems that they are facing.

Documentation in nursing consists of Assessment Documents, Vital Sign Charts, Fluid Balance Charts, Observation Charts, Medicine/Drug Chart, Informed Consent, Incident/Accident Forms and Nursing Notes. In an article from (Nursing Times 2007) it explains, Good record-keeping is an …show more content…

I feel that record-keeping is a importance in nursing, because without good nursing documentation there would be poor nursing care. Recording documents accurately allows for problems to be found and interventions to be carried out, allowing for essential patient care to be accomplished. Errors and mistakes can lead to poor patient care and possible legal proceedings for nurses if not dealt with correctly. I feel confidentiality is very important when documenting as nursing documentation needs to be legible and factual, it is important that all information is stored in the appropriate

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