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Table of Contents

Ethics is an unavoidable and necessary part of nursing practice. It involves doing the right thing and aiming to be a good nurse. A nurse focused on doing the best for patients, families and the community (Chadwick, Tadd & Gallangher, 2016, p.1). The International Council of Nurses provides some code of ethics for nurses and this is a guide for how to behave a nurse based on the social values and needs. In the ICN code of ethics, one important level is nurses and practice because, while practice in a health care setting the nurse to have well knowledge regarding the importance of nursing practice. One basic and fundamental source of information in health care is the patient record, of which nursing documentation is a part of the views of Bjorvell et al (2000). Nursing documentation is the record of patient care it is planned and delivered to the client by a professional nurse and it contains all process of the nursing process. In nursing, practice documentation has a major role. The origin of nursing documentation has started since the early days of Nightingale (Gogler et al.2008). It is worth to mention that nursing documentation was improved with the introduction of the nursing process into the clinical setting (Oroviogoicoechea et al.2008). Considering the words of Wang et al (2011) nursing documentation is defined as the record of nursing care that is planned and given to individual patients or clients by qualified nurses or other caregivers under the control of a qualified nurse. In addition, nursing documentation can be used for other purposes, such as quality assurance. Nursing documentation is considered as an important indicator of developing nursing care. According to the patient safety law nurses have to document nursing interventions (Ohlen, 2015). According to Irving et al (2006) nursing documentation can be viewed as the record of carefully planned and or care provided to patients. In the view of, Bakken (2007) nursing documentation involves a description of nursing tasks, a method of the problem- solving and decision making as well as a theoretical model of thinking and describing the care process.The effectiveness of nurse’s record is another part. In the busy working day of nurses, with the many urgent demands on your time, you may feel that keeping the nursing record is a distraction from the real work of nursing: looking after your patients (Stevens & Pickering, 2010). A good record keeping is helping for the easy hand over to next duty staff. Moreover, it measures the nurses’ quality of care. According to Stevens et al (2010), it is a good idea to keep the documents related to patients in the health care areas. Because any problem arise in the future it is easy to find the solution.Documentation is an unavoidable one in health care. Because, the healthcare team members communicate and contribute to a client’s care (Crisp Taylor, 2001).The main forms of communication including oral, written and computer-based. The main purpose of the documentation it improves the communication among health professionals, the creation of patient care plan, helps for conducting research education in health settings, it acts as a legal document. One of the important things in the documentation is done timely and it should be clear because it used for the researchers and legal use. Moreover, nursing documentation is considered an important one in nursing because it helps with the nursing process and decision making. In nursing documentation, it is essential to follow some principles it including objectivity, confidentiality, clearing and consistency. Now a day in health care, documentation demand is highly demanded. Hence, nurses concentrate the written and computerized methods. According to the view of Cheevakasemsook et al., 2006; Yu et al., 2008, the traditional paper-based documentation do not cope with modern health requirements and this may due to the written documentation process in which documentation is often repetitive and manipulation of data is not an easy process. Some studies point out the drawbacks of the paper method in which documentation is illegible, lacking information about individualized patient care, containing useless information and missing the signatures of care staff (Ammenwerth et al., 2001; Whyte, 2005; Urquhart et al., 2009). The electronic documentation it provides up to date information to health professionals about a particular patient.The documentation in nursing that provides a detailed description of the nursing activity at a higher level. A great percentage of nursing is dedicated to documenting their daily care. Nursing documentation is an extremely essential process of nursing practice and an integral piece of each nursing intervention. The nurse document each detail of the patient from admission to discharge, it including all procedures consent and report of all investigations. One of the important advantages of the nursing documentation helps to review the patient condition on next admission. It is a good idea to follow the criteria FACT (factual, accurate, complete, and timely) it gives an outline and improves the documentation process. In the present time, structured documentation is available is help for the accuracy of the data because structured documentation is taken from pre-printed data for specific aspects of the care, therefore, its focus on the nursing care upon diagnosis, treatment aims, client outcome and evaluation of care. It eliminates the errors as well as through these nurses can raise the standard of record keeping practice.In nursing practice, ethics are fundamental to nursing. All nurses respect their patients’ values and rights. For creating a mutual understanding nursing documentation is very helpful. Once a patient admit under your care record each and everything related to a patient in the patient record and a most important one in nursing care, before doing any procedure please go through the written order of the particular physician, if the written order is not present to inform the concern health professional and do it as possible. After the procedure the nurse document about all procedure, what is the condition of the patient? A problem arises a client regarding hospitalization and procedures, the nurse’s documentation act as a legal document and can be used as evidence in a court of law as well as it helps the nurses to document the care they provide to demonstrate accountability for their actions and decisions.In my point of view, documentation is an essential thing in nursing practice. In the health care, field any issues happen related to care, if the nurses correctly recorded the events in a correct manner it helps for the easy problem-solving. In the nurse’s record or nurses documentation, the registered nurse demonstrates what she did, for whom, when and with what effects. It acts as a legal document so, clearly and accurately completed the nurses’ documents not use the short abbreviations and avoid vague terms.To be concluding, documentation is the most important at the most challenging one in the health care field. Even if the documentation does not go well for your patient condition if you have documented well protect yourself from other future issues. Some professionals think that documentation is a time consuming one but, it is not a simple one in health care settings. I strongly recommend all health professional to take it as a habit in your professional life. Furthermore, it will help to complete the nurses’ duties in an efficient way. All professionals gradually improve their documentation skills and attain their final outcomes. (Castledine, 2013). In code of ethics nurses and practice this describe that nurses have some personal responsibilities while working in a team and providing care with the use of modern technology and evidenced based practice for good patient outcome.ReferencesAmmenwerth, E., Mansmann, M., Iller, C., & Eichstader, R. (2003). Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-year study. Journal of the American Medical Informatics Association, 10(1), 69-84.Bakken, S. (2007). Building standard-based nursing information systems. Washington, DC: Pan American Health Organization.Bjoevell, C., Thorell-Ekstrand, I., & Wredling, R. (2000).Development of an audit instrument for nursing care plans in the patient record. Quality in health care 9(1), 6-13.Castledine, G. (2013). The importance of nursing documentation. British Journal of Community Health Nursing, 2(8), doi: 10.12968/bjch.1997.2.8.7274Chadwick, R., Tadd, W., Gallangher, A. (2016). Ethics and Nursing Practice. Second Edition.Cheevakasemsook, A., Chapman, Y., Francis, K., & Davis, C. (2006). The study of nursing documentation complexities, International Journal of Nursing Practice. 12, 366-374.Dehghan, M., Dehghan, D., Sheikhrabori, A., Sadeghi, M., & Jalalian, M. (2013). Quality improvement in clinical documentation: does clinical governance work? 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