Nursing documentation - Essay Example

(Ammenwerth et al., 2003; Audit Commission, 2002) 'A nurse from Coventry was recently removed from the national register after failing to keep accurate records for patients in her care. She was found guilty of seven charges of misconduct. The committee heard that she failed to ensure care plans were prepared for several patients covering issues such as diabetes, pain management and dietary needs. On one occasion, she failed to notify staff of a patient's increased risk of hemorrhage following a drug error.

The Nursing and Midwifery Council (NMC) found the nurse had systematically neglected a basic and crucial duty to keep proper records for the management of patient care.' (Griffin, 2004) And this is only one of the cases found in literature, in relation to the negligence, with which the nurses treat the importance of making records. Castledine (2005) reports about the failures to carry on proper documentation in the Freda House. Freda House is described by him as the establishment for treating blind people.

Due to the improper records, which one of the nurses - Bob - was making, many patients and older people in the Freda House were mistreated and had health complications. As a result, 'The managers of Freda House decided to refer Bob to the Nursing and Midwifery Council (NMC) because of the poor explanations and excuses for his actions. He was charged by the NMC with: (1) Completing medication records when the drugs had not been administered; (2) Falsely completing nursing records relating to wound dressings which had not been changed; (3) Failing to change residents' dressings while indicating that he had done so in the patients' care plans; (4) Failing to report at handover to the nurse in charge that he had not administered drugs or changed patients' dressings; (5) Failing to clean the eyes of a resident.

' (Castledine, 2005). Of course, this only proves how nurses have got accustomed to the thought that documentation is the skill second to nursing (Tingle, 2001), not understanding its importance for the patient's health. The similar cases are also described by Tingle (2001), British Journal of Nursing (October, 2000), Johnston (1998), Moody (2001). It was surprising to read the work of Bjorvell, Wredling and Thorell-Ekstrand (2003), in which they have come to conclusion that 'most participants, regardless of group, perceived nursing documentation to be beneficial to them in their daily practice and to increase patient safety'.

Why then do we have so many reports of the health complications, which appear as a result of the misleading or false nursing records (Anderson, 2000; Charles et al, 2000; Tingle, 1998) Many articles describe the importance of carrying correct nursing records. (Wright, 2003; Scottish Executive, 1999; Nursing and Midwifery Council, 2002; Dion, 2001) For example, Owen (2005) writes in her article, that 'Documenting patient care is extremely important in the community setting as nurses usually visit patients alone, sometimes with long periods between each visit.

The only way that the nurse can legally communicate the care that has been delivered is by writing effective records. Nursing records are usually held by the patient, enabling information to be shared easily between visiting practitioners.