Nurse Standards And Documentation Nursing Essay

Nursing standards are expectations that contribute to public protection. They inform nurses of their accountabilities and the public of what to expect of nurses. Standards apply to all nurses regardless of their roles, job description or areas of practice.(College of Nurses Ontario, 2008, para.1).

Documentation is one of the vital components of ethical, safe and effective nursing practices that provide comprehensible image of the client health status and their outcomes. (Practice Standards, 2008, para.2).Whether the documentation is in electronic or written format, hence documentation communicates the nurse observations, decisions, and outcomes for the client. According to the Aga Khan University policy of Documentation of Nursing Care (2008), “documentation is a direct nursing activity that ensures the evidence for provision of nursing care and continuity of care.” (p.1.1). The quotation indicates that for every events and record it is very important to do documentation as evidence so that the staff would legally be safe. Moreover nursing care provides good and healthy communication between the staff and the patient and further this provides the good continuity of care to the patient. According to Kimberly (2003),”if it wasn’t documented, it wasn’t done.” (para.1). This revealed that in the clinical setting, if the documentation is not complete, then the work will be count incomplete.

During my senior electives in my practice setting in Private Wing II (medicine unit) I encountered many issues regarding documentation on bedside files. I observed most of the nursing staff not following the documentation policy. For example, absence of events related to abnormal vital signs, patient response during invasive and non invasive procedures, abdominal pain complaint and its monitoring scale, errors in 24 hours calculations of intake output flow sheet that can impact on patient negative and positive balance. Moreover, issues related Nasogastric feeding and patient’s tolerance ability, absence of initials and dates on weekends and wrong addressograph of patient on intake output flow sheets, non useable abbreviations, illegible writing and inaccuracy of nursing notes, all these issues identified during rounds and in morning over.

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