Accurate Written Communication And Clinical Record-Keeping

Accurate written communication and clinical record-keeping is an essential clinical skill, needed to support the interaction, reflection and measurement of care in nursing practice (Department of Health, 2010a). It can be quite complex, as there is lots of information to record and document that needs to be given or sent to others (Boyd and Dare, 2014, pp. 7 – 8). Good communication skills is needed for the provision of safe and effective care, vital to the therapeutic nurse-patient relationship development. It expresses the needs and concerns of patients by giving them a better understanding of the care they were provided (Arnold & Boggs, 2011, P.185-86). Clinical records are legal documents which show accountability for patients care. So

As it draws up the principles and values that guide, how they should behave. Regulations emphasise the responsibilities and rights of nursing staff, public and patients and provides, and provides guidance to how they’re met. Nursing is a profession, which relies heavily on legislation; such as the Data Protection Act (1998), Access to Health Records Act (1990), and Freedom of Information Act (2001) and the Human Rights Act (1998). Laws designed to protect disclosure, confidentiality and access of all personal data (National Health Service Litigation Authority, 2010). ‘Nurses duties include, adhering to the legislations, it enables nurses to respect patients’ privacy, and autonomy through the laws of negligence, consent and confidentiality; when assessing patient health’ (Cuthbert and Quallington, 2008, Pp.156-60). It also relates to other legal constraints, as set by the NHS Constitution (Department of Health, 2015) Highlighting nurse’s legal and professional duty of care. Therefore, it is important to comply current healthcare practice regulations and other legislative requirements to carry out best practice Compliance with regulations and seeking guidance of them. For example: The Nursing and Midwifery Council (NMC) Code of Conduct (2015), The Francis report (2013) and the 6C's of nursing (Department of Health, 2012). They all similarly, combine the expectations of patients, staff and the public from the National Health Service