Does good documentation equate to good nursing care?
Good documentation does not necessarily equate to good care. This article explores the potential underpinnings of poor documentation from an ethical decision-making lens. Nursing standards of care related to documentation are reviewed. The internal and external constraints of moral distress are considered, as is moral residue. Finally, the roles of the nurse administrator as well as specific remedial and restorative measures are suggested.
Bosek
Marcia Sue DeWolf
MS
Department of Nursing, University of Vermont, Burlington, VT, USA. marcia.bosek@umv.edu
Ring
Marcia Ellen
ME
D004282:Documentation / Q000941:ethics / Q000592:standards*; D004993:Ethics, Nursing; D006801:Humans; D008499:Medical Records / Q000592:standards*; D009732:Nursing Care / Q000941:ethics / Q000592:standards*; D009736:Nursing Process / Q000941:ethics / Q000592:standards; D014481:United States