The legal, ethical and professional aspects of record keeping relating it to team working in healthcare - Essay Example

The poor quality and clarity of nursing records was marked by Susan Lowson, the advisor to the Health Service Ombudsman, during The NSG conference "Information and Litigation in Healthcare" (on 11th June 2003) at Kettering General Hospital Post Graduate Medical Centre. Therefore, there is a little work to be done in the field of record quality improvement. The detailed description of a patient's case history, condition and treatment help the members of the inter-professional health care team to communicate and cooperate.

This may help when the patient receives the treatment from different specialists and the important information, such as blood group, allergic reactions, specific no compatible prescribed medicines etc. should be reported to every doctor. The records are vital in doctor-nurse cooperation as they help a nurse to follow the doctor's prescriptions and a doctor to control the smallest changes in the patient's condition without keeping him under close observation as in case of long, or life-long disease when the patient receives regular nurse care and one-day-per-month doctor's examination.

Good record should be written in a clear and accurate way (intended for a particular type of the record) to present the accurate account of treatment and care planning and delivery, and the record keeper should therefore follow special rules and recommendations of the authoritative organisations. Clear and consecutive records of a patient's condition help to detect problems rather than scrappy, incomplete, and inconsequent notes. Rigorous, detailed description of case history, the changes in patient's condition, medical conclusions, recommendations, and prescriptions help not only provide the successful treatment but also to protect the rights of a doctor or a patient in case of litigation.

Thus, a high level of record keeping provides patients' welfare. Good medical record keeping helps to provide continuity of care.Continuity of care is an important component of medical service. Continuity is not an attribute of providers or organisations, it is rather the way individual patients experience integration of services and coordination. Therefore, continuity of care is a significant characteristic of medical care level. According to Guidelines for Record-keeping (2005, p.7), the Audit Commission (1995) found patients were suffering as a result of poor communication between professionals, even within the same area of practice and/or ward/base.

The reason for that was that records were frequently treated as the personal property of a practitioner instead of as a corporate asset to promote quality care. The Trust is committed to promoting integrated patient records to support safe and effective care. It is strongly recommended, that where possible, practitioners should use or develop records that other professionals and the patient/carer/relatives are able to use to promote continuous effective care for the patient. An example of how and where this system of integrated record keeping works is the personal child health