The Importance Of Nursing Documentation

Nursing documentation as defined by the Canadian Fundamentals of Nursing is “anything written or electronically generated that describes the status of a patient on the care or service given” (Potter, Kerr, Potter & Perry, 2014). Documentation is an important aspect of the nursing profession as it serves multiple purposes; some of which include: furnishing legal evidence of care, ensuring continuity and quality of care, tracking patient outcomes, and being a reference for future follow up assessments. Because of the many uses of nursing documentation, it is important that case notes are accurate and able to clearly convey what the nurse has discovered during his or her assessment. In order to ensure this, the following principles have been established:

The Meriam Webster dictionary defines subjective statements as statements that are “based on or influenced by personal feelings, tastes, or opinions” (Merriam-Webster, 2018). These statements can be used as evidence of unprofessional behaviour or unprofessional care, as they may appear to be retaliatory or critical comments about the patient. In order to prevent unprofessionalism and steer clear of inquiries of the law, the omission of subjective statements and inclusion of objective statements – unbiased opinions or pure facts, with patient’s words in quotation marks are a must. “Patient started to cough and breathe rapidly, yelling that she is about to faint and that she can’t breathe anymore. Considering the fact that someone about to lose consciousness does not have the strength to yell, it must be concluded that the patient is faking her symptoms”. In this example, the author failed to distinguish his or her words from that of their client’s which could have consequences as in court this documentation will be regarded as hearsay as there is nothing that distinguishes it from a delusion or an actual statement. The example can be rewritten to not include the critical comment made about the patient faking her symptoms and the addition of quotation marks and would like this, “Patient started to cough and breathe rapidly, she yelled “I am about to faint, I can’t breathe anymore” her ability to yell is not congruent with the normal symptoms of an individual who is about to lose consciousness”. The removal of the critical comment has made this example professional as this nurse states only facts and does not draw conclusions or make