Study on Nursing Records in Hospital Case Sheets

Documentation in the case sheet is the prime duty of a nurse, documentation should be timely, accurate and complete. Whenever a case of medical negligence is filed against a hospital the only defence is medical record, good records always provide a good defence. A cross sectional study was done on nursing documentation in hospital case sheets at rural medical college hospital with an attached school of nursing. The objective was to appraise the importance of nursing record in case sheet with regard to various medico legal aspects. 100 case sheets were collected from the medical record department of the hospital and only the nursing information from the case sheet was collected in to a data sheet and analysed for errors. None of the case sheet was free from errors. We observed too many lacunae in the case sheets and explained how it leads to medico legal issues