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Keeping good nursing records also allows us to identify problems that have arisen and the action taken to rectify them. In short, the patient's nursing record provides a correct account of the treatment and care given and allows for good communication between you and your colleagues in the eye care team. Poor record keeping can therefore mean you are found negligent, even if you are sure you provided the correct care - and this may cause you to lose your right to practise. According to the law in many countries, if care or treatment due to a patient is not recorded, it can be assumed that it has not happened. If a patient brings a complaint, your nursing records are the only proof that you have fulfilled your duty of care to the patient. In fact, the quality of our record keeping can be a good (or bad) reflection of the standard of care we give to our patients: careful, neat, and accurate patient records are the hallmarks of a caring and responsible nurse, but poorly written records can lead to doubts about the quality of a nurse's work.Īnother important consideration is the legal significance of nursing records. Needless to say, this can affect the wellbeing of patients. Without clear and accurate nursing records for each patient, our handover to the next team of nurses will be incomplete.
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It is nearly impossible to remember everything you did and everything that happened on a shift. This cannot be more wrong! Keeping good records is part of the nursing care we give to our patients. In the busy working day of a nurse, with the many urgent demands on your time, you may feel that keeping nursing records is a distraction from the real work of nursing: looking after your patients.