Recordkeeping in Nursing
Record keeping may be defined as information that outlines any care or service provided to a patient/client, which is documented in writing, or electronically (CRNBC 2008). Good quality record-keeping is an indicator of good quality care and is an integral part of nursing practice (An Bord Altranais 2002). Record-keeping and documentation is important to ease communication between nurses and other health care professionals. Nurses communicate their nursing assessment and diagnosis of a patient, their plan of care, interventions they have carried out and the outcomes of these interventions to their colleagues through their documentation (CRNBC 2008). Good record keeping practice facilitates effective communication as outlined in An Bord Altranais’ recording clinical practice guidelines (An Bord Altranais 2002).
Record-keeping and documentation is a fundamental part of a nurse’s care and is as significant as the direct care given to patients (Griffith 2007). Record-keeping is essential to aid safe and appropriate nursing care by promoting continuity of care for the patient (CRNBC 2008). This ensures that all members of the health care team are maintaining the patient’s progress and