Accountability

Accountability Failing to maintain reasonable standards of record keeping could be construed as professional misconduct potentially resulting in nurses facing charges against their professional competency (Dimond, 2008). Nurses must remember that records can be used as evidence in complaint procedures and hearings and in some instances, these investigations can occur some years after the original events took place (Rodden and Bell, 2002). Prideaux (2011) explain that nursing records can be the prime source of evidence in such investigations and that this should, in itself, be motivation to maintain good documentation standards. Record keeping provides a testament to care that is given (McGeehan, 2007) but it can also detail attempts to deliver care but which are declined by patients. Filling in a fluid chart only when a patient takes a drink may only tell half the story about the patient; if the patient has declined drinks, this must be documented too. Evidence of a patient declining care interventions can alert staff to investigate the reasons behind the declining of care and address any underlying problems. A nurse could not defend gaps in the fluid balance chart with the response that the patient declined drinks so there was consequently nothing to document; invisible care is no care and may be interpreted by a court of law as evidencing neglect of the patient. As Griffith (2007) remarks, litigation cases are based on proof and not necessarily truth. Therefore, the documentation of nursing care can provide evidence to anxious relatives that their loved ones are receiving the quality care they deserve (Jefferies et al, 2010). Documentation in itself, is no guarantor of truth of the events recorded and the recorder may still be called into court to defend the integrity of what they have written. References Dimond, B. 2008, “Record-keeping, statement, and evidence in court”. Legal aspects of nursing. Pearson Education, London: 195–214. Griffith, R. 2007, “The importance of earnest record-keeping”. Nurse Prescribing. Vol. 5, No. 8, pp. 363–366. Jefferies, D., Johnson, M., Griffiths, R. 2010, “A meta-study of the essentials of quality nursing documentation”. International Journal of Nurse Practitioners. Vol. 16, No. 2, pp. 112–24. McGeehan, R. 2007, “Best practice in record-keeping”. Nursing Standard. Vol. 21. No. 17, pp. 51–55. Prideaux, A. 2011, “Issues in nursing documentation and record-keeping practice”. British Journal of Nursing. Vol. 20, No. 22, pp. 1450-1454. Rodden, C., Bell, M. 2002, “Record-keeping: developing good practice”. Nursing Standard. Vol. 17, No. 1. Pp. 40–42.