Record Keeping Assignment Sample

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Introduction

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Record keeping in the healthcare setting is an important process for maintaining good care to the patients. In case of contemporary nursing , record keeping is about documenting the information regarding response and care plan of the patients. Apart from that, other factors that may have an impact on a patient's health and well-being are recorded as well. This is important for an informed treatment plan.this can help in maintaining legal compliance and ensuring accurate patient care and quality of treatment delivery. This essay will discuss the key principles of record keeping which should be followed properly to avoid any ethical or legal issues. Apart from that, different processes of record keeping and impact of these procedures in managing the records have been discussed here.

Discussion

Key principles

Contemporary nursing must follow some guidance for record keeping. The guidelines provided by nursing and midwifery councils have been developed for the record keeping process (Leigh & Roberts, 2018). As per these guidelines, nurses must record the statements from the witness of the events or who can explain the event clearly. In this case, it is important to type the information clearly and that documentation must be properly dated and signed. Consent and confirmation from the person making the statement should be taken. Also, the contact information of the person should be noted as well. Copies of the records must be kept properly (NMC, 2021). Records should be factual and must avoid use of unnecessary abbreviations, or phrases. Information about the patient’s assessment and treatment plan should be recorded properly. Also, any risk or challenges faced during the patient's care should be recorded. The record should be taken in easy language and should be shared with other practitioners if necessary for an information decision making. Also, its is the duty of the nurses to maintain confidentiality of the records and must follow the legal frameworks.

These guidelines are provided by the Nursing & Midwifery Council. These guidelines have been developed by this organisation to make sure that all the nurses and midwives are following the same guidelines for their record keeping purpose (NMC, 2021). In the case of the UK, NMC organizes national programs for the ease of nurses to use the electronic record keeping process and information communication technology. In this regard, the NHS has published their Code of practice or CoP which is a guideline for managing the NHS record. This is applicable for the organisations who are working under NHS contracts and this promotes the professional practices and legal requirements for the nurses. As per the guidelines of NICE (National Institute for Health and Care excellence), caregivers must maintain a record for each medication they give on each event and their support in that case (Leigh & Roberts, 2018). Also, any kind of over-the-counter medicines should be recorded as well.

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The supports which have been discussed here include reminding the patients about taking the medicines on time, giving them the medicines, and tracking if the patient is taking or rejecting the medicine. In this case, maintaining professional accountability is important for nurses. There are different aspects where nurses are accountable for. Nurses are professionally accountable for providing high quality care to the patients and delegation. Apart from that, they must follow all the policy and procedure that nurses should follow for the care unit. Nursing Practice Act guidelines must be followed by the practitioners for their professional accountability and by doing that they must maintain confidentiality of patients as well (Leigh et al. 2020).

This is important for nurses as in many cases illegal issues may arise such as breaching code of practice or confidentiality of patient data. In this case, maintaining the Equality Act should be maintained by the nurses as patients from all the race and cultural backgrounds should be treated equally. Nurses follow Caldicott principles to follow good nursing practice guidelines and thus they are supposed to keep people safe and provide health and well-being (NDG, 2020). On the other hand, not following proper guidelines may lead to legal offenses within the healthcare setting. Following NMC guidelines is important for the nurses to avoid any legal offense and patient care risks. However, in order to follow these guidelines it is important to provide training to the nurses to follow the guidelines properly.

Range of record keeping

There are different types of processes followed for the record keeping purpose of the nursing practitioners. In case of nursing practice, verbal, non-verbal and electronic record keeping procedures are followed in general.

In case of verbal record keeping, a structured communication is mained between the nurses and the patients. In this case, initial observations are recorded including the date and time, event of the occurrence (Akhu?Zaheya, Al?Maaitah & Bany Hani, 2018). The language of keeping the record must be in understandable form while keeping the record. Clear and concise record keeping is expected in this case. Apart from that, patients' handover details should be recorded in verbal form in this case as well . Apart from the statement that the patient is providing regarding health issues or the event of occurrence, assessment requires some other observations as well. This is mentioned as non-verbal record keeping. As opined by Müller-Staub, de Graaf-Waar & Paans (2016), nor-verbal behaviors include facial expression, eye contact, body language and speaking process of the patient.

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These are some gestures and observations which should be recorded for the treatment process of the patients. Nurses must follow these aspects and keep record for shared decision making and treatment choices for the patient. Electronic record keepings are the most commonly used process in recent times. In this case, record keeping is done through computerised devices. This can occur using laptops, computers and tablets. Clinical documentation of the patient's condition is done using electronic devices (Xue & Heffernan, 2021). Vitals of the patients, medication tracking, routine check up details, dosages of medications and the time and details of the treatment are considered in this record keeping process as well. Also, auto generated notifications can be received by the nurses about the dosage and medication schedules.

In regard to this discussion, it can be stated that record keeping is important in case of nursing practice for better care to the patients. This can be effective for informed decision making as well. On the other hand, there are some factors which can be risky regarding this record keeping process (Clarke et al. 2017). If the records are not kept securely there is a huge chance of data breach. Unauthorised people can have access to the confidential records of the patients. Thus there is a chance of data misconduct in case of such a data keeping process.

Impact of record keeping

Therapeutic relation refers to a consistent and close connection between patient and the healthcare provider. This is mentioned as a therapeutic alliance. This is an important factor in providing good care to the client. Thus a bond of trust is developed between the patient and the healthcare practitioner. This commitment can help in developing a healthy bond to provide good care to the patients. There are some key factors which should be considered in order to develop a therapeutic relationship between the patient and the healthcare expert. These factors are included with acceptance of the practitioners for their patient irrespective of their cast, race or socio-economic or cultural background (Xue & Heffernan, 2021). Apart from that, showing empathy is important in this case as well. Listening to the patients carefully can help in developing this relationship. In case of nursing this is important as they are the primary caregiver and the patients must follow the instructions of the nurses for their overall health and well being. Apart from that, in case of nursing practices, it is important to develop a trustworthy relationship or a therapeutic relationship between the patients and their family as nurses are responsible to provide self care advice and process for better health after discharge (Moreno?Poyato, Rodríguez?Nogueira & MiRTCIME. CAT Working Group, 2021). The medication and doses are mentioned by the nurses as well. In some cases, family members of the patients are provided with healthcare knowledge for better care of the patient. In this regard it is important for the nurse to develop a good relationship with them as well.

Conclusion

This discussion has mentioned the role of nurses in developing patient centred care. In this regard, the role of record keeping has been mentioned as an important element as this practice can help in developing an informed decision making process. Different processes of record keeping have been mentioned here which can be effective as well as risky for maintaining confidentiality. In order to develop good patient centric care it is important to develop a therapeutic relationship between the patient family and the caregivers. The factors which should be considered for therapeutic relationships are the key factors mentioned by the NHS for a proper nursing practice which should be followed by the nurses for the healthcare setups.

References

Akhu?Zaheya, L., Al?Maaitah, R., & Bany Hani, S. (2018). Quality of nursing documentation: Paper?based health records versus electronic?based health records. Journal of clinical nursing, 27(3-4), e578-e589.

Clarke, A., Watt, I., Sheard, L., Wright, J., & Adamson, J. (2017). Implementing electronic records in NHS secondary care organizations in England: policy and progress since 1998. British medical bulletin, 121(1), 95-106.

Leigh, J., & Roberts, D. (2018). Critical exploration of the new NMC standards of proficiency for registered nurses. British Journal of Nursing, 27(18), 1068-1072.

Leigh, J., Bulpitt, S., Dunn, J., Fletcher, J., Heggs, K., Hopley, T., ... & Sigley, H. (2020). A guide to the NMC emergency standards for nurse education during the current deployment of student nurses. British Journal of Nursing, 29(11), 632-638.

Mirhaghi, A., Sharafi, S., Bazzi, A., & Hasanzadeh, F. (2017). Therapeutic relationship: Is it still heart of nursing?. Nursing Reports, 7(1), 6129.

Moreno?Poyato, A. R., Rodríguez?Nogueira, Ó., & MiRTCIME. CAT Working Group. (2021). The association between empathy and the nurse–patient therapeutic relationship in mental health units: a cross?sectional study. Journal of Psychiatric and Mental Health Nursing, 28(3), 335-343.

Müller-Staub, M., de Graaf-Waar, H., & Paans, W. (2016). An internationally consented standard for nursing process-clinical decision support systems in electronic health records. CIN: Computers, Informatics, Nursing, 34(11), 493-502.

NDG, (2020). The Eight Caldicott Principles. National Data Guardian. Retrieved on: 16th December 2023 from: https://www.research-writing.com/MRP_projects_files//NAT/chat_attachment/eight_caldicott_principles_08.12.20683.pdf

NMC, (2021). Keep records of all evidence and decisions. Nursing & Midwifery Council. ian. Retrieved on: 16th December 2023 from: https://www.nmc.org.uk/employer-resource/local-investigation/guiding-principles/record-evidence-decisions/

Xue, W., & Heffernan, C. (2021). Therapeutic communication within the nurse–patient relationship: A concept analysis. International Journal of Nursing Practice, 27(6), e12938.