My aim for this annotation is to show my understanding of Record keeping. I will show an understanding of the duties of the registered nurse in relation to record keeping, show awareness of the professional and legal implications and understand the role of the student nurse in relation to record keeping. Record keeping is an important part of nursing and midwifery practice and is used as a vital tool in giving effective care. It is not an optional tool as it may put the patient at risk for example it allows other nurses and doctors to have information of a patients that are in service of care.
Under code one of record keeping (NMC 2009) when record keeping it must be clear and accurate and they have to be completed as soon as possible. There are several positive outcomes by keeping records clear and accurate such as high standards of clinical care which includes satisfactorily assessing the patient’s conditions, taking account of the patient’s views and where necessary examining the patient. Continuity of care is also a positive outcome and Records should identify any risks or problems that have arisen and show the action taken to deal with them.
It will promote good team work as it enhances better communication which makes it easier to pass on information within the health team. Confidentiality may be breached if not careful for example people in your care should not be discussed in places where information might be overheard. Nor should records be left carelessly, either on paper or on computer screens where they might be seen by unauthorised staff or members of the public.
With these positive outcomes follows Quality issues such as the rate of professional practice is given at a high standard, it shows how skilled and safe the healthcare team is and works at and shows good team work. Records may include handwritten clinical notes, emails, letters to and from other health professionals, laboratory reports, x-rays, printouts from monitoring equipment, incident reports and statements, photographs, videos, tape-recordings of telephone conversations and text messages.
All information must not be tampered with and they must be clearly signed, dated and timed. Information must not be altered or destroyed without being authorised to do so. Computer held records allows health care professionals to Have immediate access to key information – such as patients’ diagnoses, allergies, test results, and medications – would improve caregivers’ ability to make sound clinical decisions in a timely manner.
The ability for health care professionals to participate in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care. The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should improve legibility, reduce duplication, and improve the speed with which orders are completed.
Using reminders, prompts, and alerts, electronic decision-support systems would help improve obedience with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.. Efficient, secure, and readily accessible communication among healthcare providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events. Furthermore, Administrative processes.
Electronic administrative tools, such as scheduling systems, would greatly improve hospitals’ and clinics’ efficiency and provide more timely service to patients. When sharing notes it enhances communication, this means that within the team effective communication will be more very constant, there will be less of a chance of repeat prescribing meaning that the patient that is being looked after will not get an overdose of their medication or of any sort of care that is needed. Patient held records are adapted for different areas to take account of local needs and priorities.
However, there are general principles that should always be applied in the design of patient-held records for example Patient-held records can serve as an aid to structured care to help ensure that all patients get regular checks , to help to educate the patient and the health professional in the principles of good healthcare face to face, involve the patient or carer more closely in the management plan and to enable continuity of care when patients move house, change doctors, go on holiday, or need emergency care.
Any document which records any aspect of the care of a patient can be required as evidence before a coroner’s court, a court of law or before the professional conduct committee of the nursing and midwifery council, or other similar regulatory bodies for the health and social care professions. When record keeping, it must demonstrate evidence of the practitioners’ actions, the patients’ response to those actions and the plans and the objectives that direct the care of the patient.
An initial and on-going assessment of the patients’ needs, including a risk assessment and physical health check; the preparation and completion of care plans, the review of the patients’ progress and evaluation of care will demonstrate that each step in the process has been followed and provides basis for further goal settings and actions. Records must also contain a record arrangements made for continuity of a patients care on discharge from hospital. This will show that the nurse have understood their duty of care and has not compromised safety.
The standards for record keeping in order being effective, accurate and safe records must be factual and consecutive, in order; it cannot include any abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive or subjective statements. It has to be accurately dated, timed and signed with the writers name printed alongside the entry on the page; all entries must be identifiable to the individual and if the signature is unclear a printed name must be put alongside, it has to be readable and terms that should be used are terms that are understood by the patient.
If it is not written down, it has not happened. It is a Nurses duty to protect the patient by keeping accurate record of the actions that have taken place and for the care that is given to the patient. All records must hold relevant and professional decisions. Furthermore, a registered Nurse is held professionally accountable if there is a problem with any records that are kept.
If a student nurse or a healthcare assistant was to be given the task of record keeping they must be supervised and a registered nurse must countersign this makes them professionally responsible for the entry. Retention of records means the amount of time in which a patient’s record can be kept for; it is overseen by policy and law that records can be held at a minimum of 8 years. However, for children records can be held until they are 21 years of age. Diabetes UK (2000) Care recommendations- patient-held records. Available at: http://www. iabetes. org. uk/About_us/Our_Views/Care_recommendations/Patient_held_records/ Nursing and Midwifery Council (2007) Record Keeping Advice Guideline . Available at: www. nmc-uk. org/aFrameDisplay. aspx? DocumentID=4008 Nursing and Midwifery Council (2008) The Code: Standard of conduct, performance and ethics for nurses and midwives . Available At: www. nmc-uk. org/aArticle. aspx? ArticleID=3056 Open Clinical (2005) electronic medical records, electronic health records. Available at: http://www. openclinical. org/emr. html