An exploration of the factors that affect nurses' record keeping.

Abstract

It is generally accepted that written documentation is significant not only as a communication medium in nursing, but also in the fulfilment of a number of other professional and legal obligations for nurses. The literature suggests, however, that the records nurses keep often fail either to represent the care delivered or the patient's health status accurately. This article explores a number of possible reasons for this, including: nurses' apathy to documentation; the time-consuming nature of documentation; discrepancies between nurse/patient and nurse/nurse interpretation of the significance of an event; and nurses' literacy skills. The article identifies key areas that practising nurses and nurse educationalists need to consider if accurate and reflective nursing records are to be made. Nurses should be encouraged and supported to regard record keeping as a positive contribution to patient care, rather than as a chore to be endured.