Issues in nursing documentation and record-keeping practice

Abstract

Record keeping is an essential part of nursing practice with clinical and legal significance. Good quality record keeping is linked with improvements in patient care, while poor standards of documentation are regarded as contributing to poor quality nursing care. The quality of nursing documentation has consistently been found to be failing to meet recommended standards. This article will provide an overview of the literature on record-keeping practice and examine what makes good quality record keeping and the factors that prevent nurses from achieving good documentation standards. This article will also look at ways that documentation standards can be improved and the impact that accountability has on the record-keeping practices of nurses.

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