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Importance Of Record Keeping In Contemporary Nursing

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Introduction: Importance Of Record Keeping In Contemporary Nursing

The Nurses from a professional point of view, are subjected to an increasing rate of scrutiny regarding the procedure of record-keeping. There are various legal acts like the Data Protection Act 1998 and the Human Rights Act 1998 which have played an effective role in increasing the profile of nurses (Brooks 2021). It has also led to access to health records, while patients are increasingly interested so that they could make complaints about their care (Mutshatshi et al., 2018). Comprehensive record-keeping is essential whether these complaints must be resolved by health care providers or might get settled their disputes in court. This is also an important process because the nurses must keep the field of the legal requirements as well as best practices in record-keeping. With the reference to the Code of Professional Conduct that is NMC, 2002, has been advising that the process of recordkeeping is considered as a crucial tool of the communication between nurses (Brooks 2021).

The process of recordkeeping also states that this is the responsibility of the nurses that they must ensure that the record of the health care for the client as well as the patient is considered as a good account of planning, as well as delivery of the care and treatment (Didry 2017). The recordkeeping by the nurses is written very first when the patient is involved or the clients. It should be done till the process of completion of the occurring of the event, whenever that is practical. There should be clear evidence of the planning of the care, the making of the decision, the delivery of the shared information as well as proper care and treatment (Mutshatshi et al., 2018).

Key Principles Surrounding Record-Keeping In Contemporary Nursing

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The process of record-keeping is important at every small phase as there are hands of the nurses on clinical skills (Didry, 2017). This is as stated are required for helping the nurses in maintaining the safety of the patient within the setting of health care. This is also considered quite important for monitoring and reviewing the treatment as well as the medical condition of the patient (Gusar et al., 2020). This is also quite crucial for the issues which are legal and that might arise at the time of giving proper care and treatment to the patient. The key principles of recordkeeping are followed and discussed here with reference to the Code of Professional Conduct that is NMC (Babu 2020). There are various principles in the NMC 2009 for proper record keeping. It states that one is required to record all the details of any reviews or assessments which have been undertaken. This process of record-keeping must provide some clear evidence of the arrangements that have been made for ongoing and future care (Babu 2020).

The principles of recordkeeping according to NMC, 2009, must include further details of the information about the treatment and care which has been provided to the patient. This principle of recordkeeping could help when someone puts a plan of care where the care is required for the patient (Gusar et al., 2020).

Therefore, key principles of good record-keeping are:

  • Being consistent, factual, and accurate (Stonehouse 2017).
  • Being updated as soon as possible after there is the occurrence of any event which is recordable.
  • Providing the information on the care as well as the condition of the patient.
  • The documentation must be made clear, in such a way which could not be erased (Stonehouse 2017).
  • Being consecutive and must be dated accurately, timely and all the entries must be signed.
  • All the original entries must be legible. There should be a drawing of a clear line if there is any change in sign and date.
  • It must not include jargon, slang, and abbreviations, as the organization would use some terminology.
  • The records must be stored securely and if destroyed then must follow the local policy (Kebede et al., 2017).
  • The record-keeping must avoid meaningless phrases and offensive or insulting and derogatory language.
  • It must help in the identification of the patient by keeping a record of the name, date of birth, and hospital number, on each page of the record of the patient.
  • It should be legible when scanned or photocopied.
  • There should be no absence of clarity (Kebede et al., 2017).
  • There should be no sign of inaccuracies like mistakes in spelling, missing information, or failure in recording of the action when the problems are identified.

Legal Issues Related To Record-Keeping

The principles of recordkeeping which apply to record-keeping in the setting of the community and then some legal issues could arise (Tasew et al., 2019). The gap between the planned care and the care provided is an important measure while evaluating the Nursing assignment analysis of any patient comprehensively. All the activities performed regarding the changes in the condition of the patient and other related information are supposed to be gathered during the process of assessment (Tasew et al., 2019).

The safety of the patient is to be taken as the priority and the responsibility of taking care of him cannot be omitted or compromised in any case. Appropriate preparation is quite necessary for performing the task of caretaking of the sufferer or the patient.

Various problems might arise because there are some of the records which are also left with clients and there is also a second set of records that might be kept centrally (Tasew et al., 2019). There could also be legal issues such as accessing the records and also making some developments in the future which could be arising from the governance at the clinical level are also explored. It also might cause the health care setting in losing its professional license. This would also lead to making a contribution where the quality is not accurate regarding the information of the care. This would also cause a loss in revenue or a loss in reimbursement. Therefore, these are the result of legal issues which could arise in poor patient care by other members of the team of healthcare.

How Does Record-Keeping Impact On The Development Of A Therapeutic Relationship?

There is a process of record-keeping which is systematic and thus it provides evidence of the degree of care that is taken by the counsellors or the therapists at their workplace (Feo et al., 2018). It is the process that might be useful if a client has any grievances or some complaint against the therapists or the counsellor towards a professional body or he might also take some legal action against a counsellor or therapists (Feo et al., 2018). It would also help in protecting the client or the patient against differences in relationships between client and therapists. There also could be possibilities of ethical issues around the assessment of the clients and their records. The use of ethics records is taken into consideration in the courts. Records may be especially important when there are significant periods between contacts or when the client seeks services from another professional (Feo et al., 2018).

Personal And Professional Development In Clinical Practice

The process of recordkeeping must include several professionals at a level who have different skills. These are specifically responsible for delivering that there is fine treatment and care. It is also the responsibility of the professional of the health care to keep a better record and keep reviewing all the data and the information regarding the care of the patients (McCarthy et al., 2019). As it has been already studied that one of the principles for better record-keeping must continue with better handwriting as per the code of the professional practice that is NMC, 2009, that handwriting must be legible. If in any way in which there is some documentation which has been badly written, then these documents could cause heavy problems like if any medication has been prescribed that has been recorded and have not been written clearly, then not only the type of medication but also information on administering medication gets affected (McCarthy et al., 2019).


The principles of recordkeeping state that the process begins when the patient first enters into any setting of the health care, then the first form of the documentation must be filled. This first form of documentation is a written assessment of the patient and states the needs of the care for a patient (Adams, 2019). This is also a very crucial part of record keeping as it is the starting of the care planning process. These assessment forms would include crucial information about the medical condition of a patient and what is the required care of the patients. This is also important that nurses and doctors must have all the information regarding the case of the condition of the patient which could deteriorate (Adams, 2019).


Adams, A.J., 2019. Transitioning pharmacy to “standard of care” regulation: Analyzing how pharmacy regulates relative to medicine and nursing. Research in Social and Administrative Pharmacy, 15(10), pp.1230-1235.

Babu, T.M., 2020. Record-keeping: Level of challenges experienced by nurses during the covid-19 pandemic. IJAR, 6(8), pp.352-355.

Brooks, N., 2021. How to undertake effective record-keeping and documentation. Nursing Standard (Royal College of Nursing (Great Britain): 1987).

Didry, P., 2017. The evolution of nursing record-keeping. Revue de l'infirmiere, 66(231), pp.20-21.

Essel, H.B., Awuni, T. and Mohammed, S., 2020. Digital Technologies in Nursing and Midwifery Education in Ghana: Educators Perspective, Practice, And Barriers. Library Philosophy and Practice, pp.1-16.

Feo, R., Kitson, A. and Conroy, T., 2018. How fundamental aspects of nursing care are defined in the literature: A scoping review. Journal of Clinical Nursing, 27(11-12), pp.2189-2229.

Gusar, I., Lazinica, A. and Klarin, M., 2020. Work motivation, job satisfaction, and nursing record-keeping: do they differ in surgery and internal disease departments? Central European Journal of Nursing and Midwifery, 11(4), pp.163-170.

Kebede, M., Endris, Y. and Zegeye, D.T., 2017. Nursing care documentation practice: The unfinished task of nursing care in the University of Gondar Hospital. Informatics for Health and Social Care, 42(3), pp.290-302.

McCarthy, B., Fitzgerald, S., O'Shea, M., Condon, C., Hartnett?Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M., and Savage, E., 2019. Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of nursing management, 27(3), pp.491-501.

Mutshatshi, T.E., Mothiba, T.M., Mamogobo, P.M. and Mbombi, M.O., 2018. Record-keeping: Challenges experienced by nurses in selected public hospitals. Curationis, 41(1), pp.1-6.

Stonehouse, D., 2017. Understanding the nursing process. British Journal of Healthcare Assistants, 11(8), pp.388-391.

Tasew, H., Mariye, T. and Teklay, G., 2019. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC research notes, 12(1), pp.1-6.

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