| nswick and thedely in Canada,ae University of|arnabas Health~" the Americanis currently the;ion of Medicon,of Nursing, shesburgh, and her a member of the.,ue for Nursing.In years past, most nurses believed that apatient's care was one thing, and the record ofthat care was another. Still, not every nurseagreed with this even 50 years ago. At thattime, one wrote: "Many nurses complain thatthe time spent in charting might be more prof-itably used in bedside care. Is this not failing torecognize that adequate record-keeping is partof bedside care?" Today, of course, we can no longer choosebetween giving care and keeping records. Werealize that the records we keep are not onlypart of our patient's care, they are the care.No one can really determine what' s been donefor a patient, how well it's been done, andwhat should be done in the future, until heexamines the documentation. The patient's record from the time he's ad-mitted to the hospital to the time he's dis-charged may reveal quality care or it maynot. Right or wrong, good or bad, this record isthe only handle we have on reality. The notionthat "care is good because we say it is" isoutmoded and unprofessional. What we mustaccept is this: Documentation means done andno documentation means not done. Now I'm aware that a lot of you still havedifficulty documenting patient care. You'renot sure if what you write is meaningful. Andyou suspect much of it may just be busy work. |
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