Legal and Professional Practice: Documentation and Informed Consent

Running head: LEGAL AND PROFESSIONAL PRACTICE 1
LEGAL AND PROFESSIONAL PRACTICE
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LEGAL AND PROFESSIONAL PRACTICE 2
LEGAL AND PROFESSIONAL PRACTICE
Nurses and midwives are legally bound to adhere to specific legal and ethical
requirements that contribute towards safe and professional practice. On the same note,
professionalism is an integral aspect of nursing and Midwifery practice. In particular,
professionalism is important because it contributes towards safeguarding of the health and
wellbeing and patients. Additionally, professionalism is also an essential component of the
success of a registered nurse. Therefore, professionalism in nursing entails prioritization of
patients’ needs, adherence to professional ethical codes and having the right attitude at the job all
the time. The Nursing and Midwifery Board of Australia (NMBA) plays a major role in the
promotion of professional and safe practice for Australian midwives and Nurses. The board does
through development and enforcement of standards that registered nurses and midwives need to
adhere to (Nursing Midwifery Board, 2019). Additionally, as part of maintaining safe and
professional practice, registered nurses also need to seek informed consent when dealing with
sensitive matters regarding their patients and strictly follow documentation requirements. The
focus of this paper will be on Documentation and informed consent.
Documentation
Documentation is an essential aspect of safe and professional practice. Therefore nurses
are tasked with the responsibility to maintain accessible accurate and precise documentation of
patient’s information (Stevens & Pickering, 2010). Additionally because of the crucial role
played by nurses in healthcare organizations, the accountability of all patient information used
across the organization falls on nurses. To illustrate, nurses work in various settings such as
administrative office or bedside. They are therefore responsible for documenting patient

LEGAL AND PROFESSIONAL PRACTICE 3
information that can be used by other members of the healthcare teams such as non-nurse
members (Stevens & Pickering, 2010).
Additionally, documentation is also essential for several other reasons. These include
aiding communication between healthcare team members, creation of care plan for patients and
research purposes. Similarly, students in various schools also use patient’s files as educational
tools. Finally, documentation makes it easy for patients to obtain compensation from insurance
companies whenever it is required. Therefore, high-quality documentation is a necessity in
healthcare setting and an important aspect in the work of a registered nurse (Nursing World,
2010). For this reason, nurses need to be provided with adequate time and resources to carry out
documentation activities more effectively.
There are several documentation strategies that a nursing or midwifery student would use
during clinical placement to ensure that their practice is professional and safe. The first aspect
that they need to consider is being objective. In this regard, all patient assessments need to be
carried out using all the four human senses, i.e. the sense of smell, hearing, sight, and
touch(Kebede, Endris & Zegeye,2017). Additionally, being objective also entails documentation
of only facts and not individual opinions. To make sure that they remain objective a nursing or
midwifery student need to record the exact words said by a patient during documentation
(Austin, 2011). This is also important in the avoidance of biasness. In the same way, the patient’s
behavior needs to be described using direct quotes as opposed to the use of labels. Additionally,
the refusal by a patient to adhere to the prescribed treatment should also be documented
mentioning the reason cited as the cause of rejection by the patient whenever possible.
Secondly, they should also carry out the documentation simultaneously with the patient’s
treatment or assessment. The inclusion of dates and time for each documented entry should be