Legal and Professional Requirements for Nursing Progress Notes
Nursing progress notes are an important legal and professional documentation that provides a clear picture of a patient’s condition, treatment, and progress during their hospital stay or time under a nurse’s care. As such, it is imperative for nurses to understand the basic legal and professional requirements for documenting progress notes appropriately.
From a legal standpoint, progress notes need to fulfill certain criteria to stand as legal evidence in a court of law if needed (1). Notes must be documented in a timely manner, preferably at the end of each shift or patient encounter to accurately recall details. They should only include objective factual information rather than subjective opinions. Each entry must also clearly mention the date and time it was recorded. Legally, poor documentation practices could make nurses vulnerable to lawsuits if patient care issues arise.
Ethically, thorough and accurate progress notes are necessary to maintain high-quality, patient-centered care. This involves documenting relevant changes in the patient’s condition, treatment plan, completed tasks as well as goals for the next shift (2). Notes from different nurses should present a cohesive picture of the patient’s clinical trajectory for continuity of care. Omitting or falsifying important information violates a nurse’s professional responsibility.
From a practical point of view, concise yet comprehensive notes are easier for other healthcare providers such as physicians and therapists to review and draw important insights about a patient (3). Following a standardized format and language common in the medical field ensures clarity and consistency. Subjective and objective data should be separated for easier retrieval. Any abbreviations used must be ones approved by the particular healthcare facility.
In summary, proper documentation in nursing progress notes is foundational to meeting legal, ethical and professional standards of nursing practice. With diligent adherence to basic requirements, nurses can rest assured they are providing comprehensive yet efficient patient care records to benefit both their clients and the healthcare team overall (4,5,6).
References:
American Nurses Association. Nursing Documentation: Scope and Standards of Practice. Silver Spring: Nursebooks.org; 2010.
Geiger NA. Nursing Documentation: How to… Avoid Malpractice Claims and Boost Patient Outcomes. Am Nurs Today. 2017;12(5):24-27.
Dougherty MB, Lister S, eds. The Royal Marsden Manual of Clinical Nursing Procedures. 9th ed. Oxford, UK: Wiley-Blackwell; 2015.
Potter PA, Perry AG, Stockert P, Hall A. Fundamentals of Nursing. 8th ed. St. Louis, MO: Mosby Elsevier; 2013.
Registered Nurses’ Association of Ontario. Documentation. 2nd ed. Toronto, ON: Registered Nurses’ Association of Ontario; 2013.
Nursing and Midwifery Board of Australia. Registered nurse standards for practice. Melbourne: Nursing and Midwifery Board of Australia; 2016.
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