Legalities of Nursing Documentation
Nursing practice is regulated by federal as well as state laws. Federal laws that regulate nursing documentation include the 1998 Human Rights Act and 1996 Heath Insurance Portability and Accountability Act. The aspect of documentation is, however, mostly regulated by state laws. State laws specific to nursing practice are termed nursing practice acts. These acts can have associated rules and regulations. With regards to documentation, the purpose of nursing practice acts in all states is to give a clear and accurate of a client or patient for the time he or she is under the care of a healthcare team. This mandate of nursing practice acts is thus broad in its objective with details being left to specialty organizations, healthcare institutions, and practice groups. Therefore, when documenting, nurses should first consider the governing state legislations then institutional policies and procedures and lastly, guidelines from pertinent specialty organizations. In instances where there is a conflict between state legislations and institutional policies, state regulations trump institutional policies (Campos, 2010).
Specialty guidelines are not legally binding. They, however, create a benchmark for care for patients in a given setting. The standard of care so created is useful in litigation as it is used as a benchmark for determining what a nurse’s duty or action should have been: what a reasonable and prudent nurse would have done in a similar situation. Standards of nursing practice are set by boards of nursing. Each state has a board of nursing whose major goal is to protect public welfare by ensuring that every individual holding a nursing practice license in a state is competent for safe practice. These boards do these by setting regulations on licensing, practice, and disciplinary processes that are enforceable by the law (National Council of State Boards of Nursing, n. d.).
It is important for nurses to acquire knowledge on the legalities of nursing documentation because a patient’s health records are admissible as evidence in a court of law in case of litigation (McLean, n. d.). Cardexes, incident reports, letters exchanged between professionals, and communication books come into scrutiny by professional disciplinary boards, hospital committees, and court of laws in case of complaints of for instance negligence by patients or their significant others. The accuracy and completeness of nursing notes in such cases has a bearing on the credibility of the information contained in the notes as well as on the personal credibility of the author (McLean, n. d.). In essence, therefore, it is important for nurses to be aware of the legal guidelines related to documentation so that they can conform to these laws and regulations when documenting.
On the impact of legal guidelines on documentation on the nursing profession, these guidelines have helped to standardize nursing documentation practices (Campos, 2010). Legal requirements on nursing documentation dictate what should be included in nursing notes for instance patient assessments, diagnosis made, interventions implemented, and evaluation of the effectiveness of the interventions. In so doing, these guidelines help standardize the manner in which nurses document care. The legal guidelines on nursing documentation have additionally established a benchmark against which the quality of nursing records and care rendered to a patient can be judged.
In conclusion, this paper has analyzed the legal guidelines affecting nursing documentation. It has established that these guidelines include federal and state laws, institutional policies and procedures, and guidelines by specialty organizations. The paper has also established that it is important for nurses to be aware of these guidelines as nursing notes are admissible in courts of law as evidence. In addition, such awareness will help them conform their documentation practices to the specified guidelines. Lastly, the paper has established that legal guidelines have helped standardize nursing documentation practices.
References
Campos, N. K. (2010). The legalities of nursing documentation. Men in Nursing, 40(1), 7-9.
McLean, P. (n. d.). Charting: The legal aspects. Retrieved from http://www.cnps.ca/index.php?page=86
National Council of State Boards of Nursing (n. d.). Model Nursing Act and Rules. Retrieved from https://www.ncsbn.org/312.htm.
