Recordkeeping in Nursing

Issues and dilemmas highlighted by this incident Management issues Several management issues where highlighted by the incident. The analysis will focus on record keeping, effective communication, risk management and ethical issues. The day to day management issues affecting nursing practice such as record keeping, effective communication and risk management do not operate in isolation but are frequently interdependent and affect each other. The central focus will be on the observed failure by the night duty nurse to record or pass on information on Mark’s report. The Nottinghamshire Healthcare NHS Trust (2009) policy on record keeping states that a record of an event must be made immediately or within 24 hours of the occurrence. The rationale for this requirement is that an immediate record of

Identifying patients is key in preventing medication errors and relates to provision 3 in the code of ethics, “The nurse promotes, advocates for, and protects the

From early on, nurses learn to use their better judgment when providing care. Thinking critically can aid nurses greatly. Considering this, standard precautions are viewed as a systematic approach at preserving the well being of themselves and others. But if all of this is true, then what prevents nurses from implementing standards of precautions in their daily practice with each patient they care for? The purpose of this paper is to explore what factors may influence nurses to become noncompliant. For varying reasons, data shows that nurses have the lowest reports of compliance. Therefore, it is especially necessary to analyze these factors and educate nurses on the importance of adherence. Factors such as lack of knowledge, time pressure, and poor practice and/or qualifications contribute greatly to nurses not adhering to their standards of precautions when proving patient

Core concepts include, what is the Electronic Health Record?, how does the Electronic Health Record relate to nursing informatics?, what is the significance of the use of the Electronic Health Record?, who benefits from the use of the Electronic Health Record?, and how secure are the Electronic Health Records? An initial understanding of the core concepts will provide the foundation for understanding how the Electronic Health Record is transforming the way nurses provide patient care.

Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to

Battié, Renae. "Accountability in Nursing Practice: Why It Is Important for Patient Safety."Association of PeriOperative Registered Nurses 100.5 (2014): 537. AORN Journal. Elsevier, Inc., Nov. 2014. Web. 24 Apr. 2017.

Clinical Documentation has been used throughout the healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technology that helps maintain patient’s privacy and to direct care of the patient. Both Computer systems and EHRs can facilitate and improve the clinical documentation methods, which is beneficial for all patients, the care teams, and health care organizations. In this case, clinical documentation improvement has a direct impact on patients by providing quality information. However, the new technological change can also address the health care system efficiencies that differ from paper-based charting. Obviously, the implementation of clinical documentation is essential to enhance the provision of safe, ethical, and effective care.

In a true therapeutic nurse-patient relationship, establishing trust is a key factor to promote quality and compassionate care. This trust can be easily jeopardized by a breach in confidentiality of the patient’s personal health information. This paper will focus on the importance of confidentiality as it relates to nursing and patient information and the vulnerabilities that can attribute to breaches of that information. Whether verbal, electronic, or written documentation, confidentiality must encompass all information obtained about a patient and exist only on a need to know basis among those healthcare professionals involved in that patient’s care. In today’s age of information technology and the use of electronic medical records, a patient’s personal health information may be vulnerable to inappropriate misuse. When confidentiality is broken then the ever important nurse-patient relationship is broken. The ethical dilemmas and legal issues that accompany confidentiality breaches can result in large fines and lawsuits against healthcare facilities and also end nursing careers. It is the patient’s right to have his or her personal medical information protected at all times and the nurse must understand the responsibility to protect that right is an important factor in maintaining the nurse-patient relationship.

"If it is not written, it was never done" this mean that if it was not written down it could be lost and forgotten as time goes by like if it never happened. You can only prove what you did by the documentation that you do. If you don't document it, then you can't prove you did it. A proper documentation is always important in a healthcare setting. By having incorrect information or no information at all it may result in serious injury or death of a patient, that why it very important to keep track of all information of a patient, not only to protect the patients but also to stay on the right side of the law. The record is a legal document so everything that you write is memorialized permanently and what you don't write is questioned forever.

When it comes to documentation the mantra of phrases, “If it was not documented, it was not done” resides with many nurses.  As Weiss and Tappen (2015) describe, “If a nurse did not ‘do’ something, he or she will be left open to negligence or malpractice charges.” Documentation is of utmost importance, and nurses are taught that the most valuable piece of information that can deter them from possibly losing a lawsuit is in fact, documentation. Nurses must be thoroughly knowledgeable of how the process of documentation works.

Records are a fundamental piece of patient care and some portion of the professional obligation of care owed by the nurse to the patient (NMC, 2002) and they also state that record keeping is an essential part of nursing care and promotes the provision of safe and competent practice (NMC 2009c). Furthermore, (Tingle, 2002 and McGeehan, 2007) suggests that the quality of nursing documentation continues to be of poor standard. Additionally Calfee (1996) further agrees that documentation is as essential as care, “If it is not documented, it did not happen”. Dimond (2003) implies that the information security act likewise exist to ensure wellbeing bodies in withholding certain data considered unsafe to a

This nursing process has evolved to promote effective communication between health care professionals, a venue for analysis of health care, a source for continue nursing education, and the legal document of the patient’s medical state. Since computers were introduced in healthcare, nurses have optimized documentation adapting advance systems to help them with work and have understood the advantages of shifting manual documentation process to an electronic one and with these hospitals have turned to vendors to come up with a more customized and friendly system to facilitate nursing

Nurses’ documentation in the patient record has different purposes-from ensuring accountability and justification for patients’ interventions provided to ensuring quality, continuity and security for patients through a trajectory of illness (Gjevjon & Hellesø, 2010). When this process is done using health information systems (i.e. EMAR or EHR), it is called electronic documentation (eDoc.). According to Abiri (2014), eDoc help with mitigating medical errors and improving patient safety which are indices of quality patient care.

At a practice level, the importance and guidance of the Code of Conduct, Code of Ethics and NPA are demonstrated on a daily basis with regard to the issues of documentation, informed consent and open disclosure, and confidentiality. With respect to documentation, nurses must be able to document patient assessments and responses in an accurate, comprehensive and confidential manner and record all observations objectively. Informed consent and open disclosure are also major legal issues nurses face daily. It refers to the communication between the patient and health professional that results in the patient's agreement to undergo a specific procedure and requires that the patient has thoroughly understood the procedure, implications and risks prior to giving written consent.

The nursing notes are “expected [to be] thorough documentation for patients across the trajectory of illness; anything less places patients and the organization at a disadvantage” (Pasek, Lefcakis, O’Malley, Licata, & Jackson, 2009, p. 102). The implications of poor note taking