Each state in the United States has its own Nursing Practice Act, and Board regulations that regulate nursing practice. Although the sections that deal with documentation can vary from state to state, they all generally cover a few common topics.
The Nursing Practice Act (NPA) and Board regulations that deal with documentation are divided into:
- Record-Keeping requirements: These sections outline in general the documentation requirements, such as what information must be recorded, how records should be stored, and when they need to be completed and retained.
- Documentation requirements as part of standards of nursing practice: This section may contain documentation requirements as part of an overall standard of care. For example, accurately documenting interventions, assessments and evaluations.
- The scope of practice: This section may include documentation relating to nursing roles or responsibilities such as documentation for medication administration, patient record maintenance and the management of records.
- This section may include expectations regarding professional conduct in relation to patient documentation. For example, it could outline that the patient should be treated with respect and confidentiality.
Nurses should be aware of specific provisions of the Nursing Practice Act, and Board regulations that pertain to documentation in the state where they practice. This will help nurses to meet the ethical and legal requirements of documentation. Documentation is vital for providing quality, safe and effective nursing care.