Recordkeeping in Nursing

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

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

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.

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

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

Confidentiality is critical for nursing professional to understand and undertake. If a nurse did not keep a

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.

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.

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.

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.

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

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

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.

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.

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