One of the concepts emphasized when I was in my pre-licensure nursing program was "if it wasn't documented, it wasn't done." As an ADN, the responsibility that goes with this statement is an embedded indoctrination regarding the importance of documentation. The changes in healthcare laws, the methods of medical reimbursement and even electronic documentation have us documenting how often we take a patient to the bathroom. Rosale Lobo (2012) in her book Guilty or Innocent?: Protecting Your License Through Proper Nursing Documentation states that documentation is the way we describe and defend the care we provide. Our documentation must demonstrate a standard of care, support that care within our scope of practice, establish reimbursable care and be able to stand up to the judgement of federal and state guidelines as well as professional associations and your employer's policies and procedures. I embrace the socialization of the RN-BSN process, but the awareness is both exciting and daunting.
References: Lobo, Rosale (2012) Guilty or Innocent?:Protecting Your License Through Proper Nursing Documentation, PESI HealthCare - PHC Publishing Group; 1 edition (May 15, 2012).