DOI: 10.1097/01.NUMA.0000359202.59952.d2

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PMID: 19667913

Issn Print: 0744-6314

Publication Date: 2009/08/01


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The legalities of nursing documentation

Nikki K. Campos

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Author Information: is the chief nursing officer at Renaissance Hospital in Houston, Tex.

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Excerpt

One may wonder why the bar is set so high in the healthcare arena. The simple fact of the matter is that we as nurses have the privilege of taking care of people. This may sound like an easy concept but when compared with other service industries, it's clear that the "service" nurses provide for someone's life or well-being bears a far greater significance to the public than repairing automobiles or preparing taxes. An annual Gallop poll suggests that in the category of honest and ethical professions, nursing consistently ranks the highest, with pharmacists, veterinarians, physicians, and dentists following closely behind.1 The consistency with which nursing takes the lead with scores of "very high" or "high" suggests that the general public has a significant degree of trust that nurses will fulfill their roles with honesty, integrity, and accountability.
In order to meet the expectations of the public, nurses must fully understand the duties associated with their position as set forth by not only governing bodies, but also the institutional policies and procedures affecting their practice. One particular duty that deserves significant emphasis is the requirement of complete and accurate documentation related to patient care, which includes what's done to and for the patient and how particular decisions about care are made.2,3 This article will provide direction and guidelines for nurses when documenting care for patients.
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