( 2017) revealed that nurses do not record their actions to a great extent and they only record observations when there are abnormalities and such incomplete recording may lead people to think that they did not fulfil their duties. 2014).Ī study conducted by Genctuc et al. Despite numerous efforts by nurse managers to improve record-keeping, inadequate recording remains a global challenge in public hospitals which is frequently reported in research findings of many nurse researchers (Okaisu et al. Poor record-keeping does not put the patient at the centre of care but increases medico-legal risks and hinders tracking of clinical care decisions and care goals. Thus, poor record-keeping practices amongst nurses lead to breakdown in communication amongst health care professionals. ( 2016) found that sub-standard documentation of nursing actions is associated with prolonged hospital stay of the patients and increased patient mortality. The South African Nursing Council (SANC) Rules and Regulation R387 relating to Acts and Omissions requires a nurse to keep clear and accurate records of all nursing actions done to the patient at all times and failure to do so constitutes a professional misconduct where the SANC may take disciplinary action against such nurses (SANC 2005, R387 as amended). Furthermore, poor record-keeping not only undermines patient care but makes the nurses more vulnerable to legal claims which arise from breakdown in communication that results from incomplete or inadequate records (Marinic 2015). Without complete recording there is no evidence to prove that care was provided to the patient, and in nursing practice there is a saying that ‘what is not recorded has not been done’ (Marinic 2015 Taiye 2015). Good nursing practice requires detailed record-keeping that is comprehensive, timely and accurate.
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