Chart documentation: far reaching concerns

The documentation of patient care is a critical nursing function. In addition to confirming that the nurse has practiced within the standards of care, the documentation is intensely scrutinized by those making payment and legal decisions. With the stroke of a pen or the tap of a keyboard the nurse records a fact or observation that will forever be a part of the data base. That data base may be used to determine benefits, allocate resources, settle legal arguments and even weigh criminal justice. Charting on the patient's record is both a privilege and a responsibility. It is not to be taken lightly. Every effort should be made to write from the perspective of a neutral reporter. The scope of documentation should be comprehensive and relevant. Observations should include the realms of psychosocial and emotional concerns as well as the physical. It is not necessary to make judgements or draw conclusions about the observations charted. It is enough to record pertinent assessments, actions and outcomes. It is from a database with these characteristics that we may be assured we are practicing in an ethical and responsible manner.