The importance of nursing documentation

The use of the nursing record as a tool to document, plan and evaluate patient care has long been advocated but not always effectively implemented. In fact, recent reports by a Commons select committee and the health services ombudsman have resulted in the Chief Nursing Officer, Yvonne Moores, having to lead a government initiative to improve health care documentation. Medical and nursing records stand as the most important means of communication among those delivering care, especially in the community. Unfortunately, many doctors and nurses are not reaching the required standards or guidelines set out by the General Medical Council or UKCC. Writing and documenting nursing care is not easy and there is an urgent need to educate nurses at all levels to improve their skills. In fact, it seems that there is too little emphasis and time devoted to writing and recording nursing in pre-registration courses. The same is also true when one reviews the curriculum content of many post-registration, specialist community nursing courses. Everyone seems to assume that you eventually pick it up and gradually become a good writer and documents of care.