Record Keeping in Patient Care - Coursework Example

These include, focus on the extended primary care team as the prime means of healthcare delivery, improved keeping of patients' records and communication between professionals, and greater recognition of consumers' wishes for good quality and well coordinated care (Department of Health, 2003). Apart from these, clinical leadership, continuous learning, integration of technology with primary care, integrated record keeping of patients and many other elements are of primary concern in modern primary care.

However it is the last element just mentioned that this article aims at further exploration. Record keeping deals with the storage of accurate information about the patient and all other data that concern primary care administered to the patient. A good record of a patient not only forms a basis for historical record but also acts as a form of communication among the care providers. This article aims at understanding the importance of accurate record keeping and its role in extending high quality health care to patients.

The article also seeks to identify the various forms of record keeping options available for health care professionals, with the merits of each form. The elements of effective record keeping and the barriers that hamper health care professionals from ensuring that these elements are ensured are also analysed.  Record Keeping: An Imperative Requirement for Patient Safety What exactly is a Health Record Data Protection Act (1998) defines a health record as a record consisting of information about the physical or mental health or condition of an identifiable individual made by or on behalf of a health professional in connection with the care of that individual.

Maintaining accurate health records form an integral part of the nurse's activities. The Nursing and Midwifery Council emphasizes this point by publishing that, good record keeping is a mark of a skillful nurse (NMC, 2002). The necessity of accurate record keeping can not be exaggerated. The NMC in it's a-Z Advice Sheet (NMC, 2006), has suggested that, good record keeping helps to protect the welfare of patients by promoting: High standards of clinical care: The clinical care experienced by the patient can be elevated if everyone associated with the team providing care to the patient is well aware of his past records.

Continuity of care: Health records of a patient act as a means to continue the primary health care. In cases when the patient mite move from one hospital/clinic to another, the patient's health records smoothen the transition. Better communication and dissemination of information between members of the inter-professional health care team: This is a primary benefit obtained through effective record keeping. Health record acts as the medium of communication about the health and care of the patient to everyone involved in imparting health care.