Keeping Nursing Records - Essay Example

Keeping Nursing Records Record keeping refers to an automated or manual system responsible for collecting, organizing, and categorizing records to facilitate their preservation, use, retrieval and disposition. This system has four main components for its efficient performance. They include; records, people, processes and tools (Geyer 2006). Records entails the information created or received for action, people-entails the records contacts, records staff and the Records Liaison Officers in charge with over seeing the records management program. Processes involve the procedures conducted to manage records, and tools in a record system comprise all the software and equipment used in capturing, organizing, storing, tracking, and retrieving records. Keeping records is essential for the best functioning of any organization. Nursing being an important entity that supports human development and growth, it also relies on good record keeping for efficient delivery of services and health care (Luepker 2003). Therefore, it is the responsibility of every nurse in the nursing team providing patient care to play part in record keeping. However, a senior nurse overseeing unqualified colleagues should assume the responsibility and provide guidance on proper documentation. Keeping nursing records has many advantages, however, a majority of nurses struggle to find time to keep records. In addition to that, some of them do not view it as vital as other duties. Nursing record entails the nursing care a patient receives, as well as his/her response to the care. Additionally, factors or events that may affect a patient’s well being are also recorded. These factors ranges from the patients’ visitors seeing them to scheduled theatre visits. In case a nurse does not know what to write down in a patient’s heath record, he/she should ask such questions as: “If I am not able to handover verbally to the next nursing team, what information should they know to continue giving heath care to the patients?” Answers to this question should give the nurse an insight of what she is expected to write in the patient’s records (Marsh & Magee 2009). Good record keeping is part of nursing care given to patients. As a matter of fact, it is almost impossible to memorize everything one does or everything that happens in a shift. Therefore, failure to have accurate and clear nursing records for all patients may make handover to new nursing teams incomplete. Furthermore, this may affect the patients well being. Quality of records kept by a nursing department may be a good or bad reflection of the care given to patients (Caldicott Committee 2004). Neat, accurate, and careful patient records acts as a hallmark of a responsible and caring nurse. On the contrary, a poorly written record brings doubts on the quality of work being done by a nurse. Nursing records also have legal significance. In cases where; patients, family members, or attorneys file complaints questioning the quality of heath care administered, nursing records become vital in providing proof that a nurse fulfilled his/her duty while taking care of the patient (Fisher 2003). Comprehensive and well written heath records give detailed information that best describes what actually took place. Most countries have laws that consider lack of patient treatment record to mean no care took place. Therefore, poor keeping of records may mean that a nurse is negligent, even if he/she provided the best or correct care. This may lead to loss of one’s right to practice. Good record keeping facilitates the protection of the patients’ welfare by encouraging high standards of clinical healthcare, allowing improved communication between health care team members, as well as giving correct accounts of treatment. Furthermore, it gives nurses the opportunity to detect problems arising at early stages so that they may recommend appropriate actions to rectify them (Suchman 2003). Patient’s nursing records are examined by healthcare planners to determine patterns and trends of illness. This study is extremely important in selecting best treatment for individuals or in searching for better treatments for definite heath complications. Computer databases storing heath records also provide exceptional opportunities for research in heath care. This research is essential for improvement of existing flaws in the provision of health care (Suchman 2003). Health care records also acts as excellent educational tools. Heath care learners and students benefit a lot from reading and comparing information they obtain from heath records. The data from various clients broaden their knowledge on illnesses, health, responses, and treatment. This knowledge equips them for their future roles in the provision of health care to patients. It is mandatory for patients’ health records to provide current, accurate, comprehensive, objective, but concise account of patients stay in hospital (Eve & Elizabeth 2000). Nurses should use a standardized form when keeping heath care records. The standardized form ensures consistencies and improves the qualities of written records. The systematic approach to provision of heath care should be documented consistently. Therefore, nursing records should consist of assessment documents, planning strategies, implementation and evaluation plans to ensure continuity of health care. The records should not be written pencil, but in black ink. This ensures they stay long without fading or being erased. The identification sheet on every heath care record bears a patient’s personal data; name, next of kin, address, age, patient’s number, the person giving care, just to mention but a few. These bits of information are vital in that they guide nurses not to use another patient’s information on another patient, complicating issues further (Eve & Elizabeth 2000). The information on the next of kin and the patient’s address are also important to the nursing staff. In case an emergency arises and the patient’s family members are needed, the nurse on duty simply goes through the records to obtain the number and the name of person to call. This can help a great deal in emergencies where a family member’s consent is needed since the patient may not be in a position to make sound decisions. During admissions, the patient’s; pulse, blood pressure, visual acuity, respiration, and temperature should be recorded. In addition to that, diagnosis and the problems the patient is suffering from are stated clearly. This bits of information are important when administering treatment and prescribing drugs to the patient. These records give the state of the patient during admission. The nursing records should be kept at a strategic position where they can be accessed with ease. Most hospitals considers the region where nursing teams meet to change shifts as the most appropriate place to store patient records (Knapp & Vande Creek 2007). This ensures that records are availed during handover sessions, and are easily accessed by all the members of the nursing team. The handing over may occur in the presence of the patient. Additionally, nursing records are considered exact if patients were involved in the health care decisions. Once the patient has been discharged, the medical records should not be thrown away or burnt, they should be filed in the medical notes folder for future use. Patients have the right to access their health records. This is a provision by the Data Protection Act of 1998. It strives to gives clients and patients the authority to access their computer-held and paper-based records. On the other hand, nurses are professionally accountable for all the information in the heath records (College Research Unit 2005). They are not supposed to reveal to any third party information regarding a patient’s health. This principle of confidentiality enables patients to be free while revealing information about them since they are sure they will not be exposed to the public (Gustafson & McNamara 2006). In conclusion, nursing records plays important roles in ensuring patients are well taken care of. Information from these records may also be used in clinical reports and audits. Consequently, this contributes to the improvement of qualitative treatment outcomes; thus making nurses achieve their goals and objectives of giving quality health care to patients (Record keeping 2007). References Caldicott Committee , 2004, Report on the Review of Patient-Identifiable Information, London Department of Health College Research Unit, 2005, Clinical Governance Support Service, Info Sheet 13, Clinical Notes. Eve, B. & Elizabeth, R., 2000, A history of the General Nursing Council for England and Wales, London, Fisher, C., 2003, Decoding the ethics code: A practical guide for psychologists, California: Sage Publications Geyer, N. 2006, Record Keeping (Professional Nurse Series), Johannesburg: Juta Academic Publications Gustafson, K. & McNamara, J., 2006, Confidentiality with minor. Professional psychology: Research & Practice, 18, 500-509 Knapp, S. & Vande Creek, D., 2007, “Confidentiality, privileged communications, and record keeping.” In Practical ethics for psychologists: A positive approach, Washington: American psychology association Luepker, E.T., 2003, Record keeping psychotherapy and counseling: Professional standards and Cases, New York: Oxford University press Marsh, D. & Magee, R. (eds)., 2009, Ethical and legal issues in professional practice with families, New York: Wiley Merlone, L., 2005, “Record keeping and the school counselor.” Professional School counseling, 8, 370-380 Moline, M. , Austin, K. & Wiliams, G. , 2001, Documenting psychotherapy: Essentials for mental health practitioners, California: Sage Publications Nursing and Midwifery Council, 2002, Guidelines for records and recordkeeping. Patterson, T., 2008, Couple and family documentation sourcebook, New York: Wiley Publishers Record keeping, 2007, Nursing Times.net, accessed 27 March 2012 from http://www.nursingtimes.net/whats-new-in-nursing/record-keeping/360932.article Rosdahl, C. & Thompson, 2007, Textbook of Basic Nursing, Philadelphia: Lippincott Williams & Wilkins Publishers Suchman, L., 2003, Plans and Situated Actions, New York: Cambridge University Press Zuckerman, E. 2006, The paper office (3rd ed), New York: Guilford Press Read More