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Accurate Written Communication And Clinical Record-Keeping

399 Words2 Pages

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 …show more content…

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

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The ANA Scope and Standards of Nursing Practice include a list of standards. These standards are statements, which summarize what is expected from nurses in professional nursing practice. The standards form the foundation for decision-making and provide nurses with direction including which actions to take (Nursing: Scope and Standards of Practice, 2015). The ANA Code of Ethics for Nurses with Interpretive Statements aids as the ethical structure in professional nursing and offers direction for the future. The ANA Code of Ethics includes nine provisions, which summarize the main ethical ideas, values, and morals for the nursing profession and provides a guide for nurses to use in ethical analysis and decision-making, including which actions to take (Code of Ethics for Nurses with Interpretive Statements,

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Legislation is defined as law which has been produced by regulatory bodies implementing a function of requirements, restrictions and conditions, setting standards in relation to any activity and securing compliance or enforcement. The regulators responsibility is to protect the service providers and its users. Compliance is either a state of being in accordance with established guidelines, specifications or legislation or the process of becoming so. One regulatory body, The NHS Litigation Authority (NHSLA) manages negligence and other claims against service providers in England. The NHSLA also helps to resolve disputes fairly, share learning about risks and standards in the NHS and help to improve safety for patients and staff.

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The Code of Ethics is an evolving document, reflecting the intertwined matrix between changes in the nursing profession and evolution in the social order. The Nursing’s Social Policy Statement (NSPS) is closely tied to the ANA Code of Ethics, and explores the foundational elements behind nursing’s social contract (ANA, 2015). The academic fields of philosophy and government brought about the idea of social concept. Social contract may be written into law and professesional codes of ethics, however the essence of the concept remains unwritten (ANA, 2015). As social concept related to nursing, the NSPS guidelined do not center around the nurse-patient relationship but rather focuses in the broader relationship between nursing and society.

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In this section, I will start to talk about the nurse practice act and how it improves patient care around the world. The Nurse Practice Act is laws that define responsibilities of the nurse and the scope of practice within their range. The range of activities and services as well as the qualifications for practice. The act describes what constitutes unprofessional conduct of misconduct and investigation and the disciplinary procedures for complaints filed against a nurse. These acts are in place to protect patients and families from harm as a result of unsafe or incompetent practices of unqualified nurses.

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The third legal area relates to legal agreement that nurses accept to a bind by the Australian Nursing and Midwifery Council’s (ANMC) Code of Ethics and Code of Professional Conduct for Nurses in Australia. These codes provide guidelines to help nurses in their practice. Statement 7 of the Code of Ethics states that nurses have to record documentation and it cannot be changed by someone. Conduct statement 7 of the Code of Professional Conduct relates to the nurses owe a duty of care. Additionally, Statement 5 of the Code of Ethics states that the nurse value to inform the decision making.

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The various nursing roles include decision-making, patient safety, safe environment, communicate effectively with the healthcare team, and participate in updating healthcare policies and procedures. Registered nurses can build their clinical and professional capabilities through education, clinical experience, a context of practice, relevant legislation and the employment setting to develop skills that remain within the legislated professional practice standards, codes, and competencies. RNs should only deliver care within their scope of practice. A tool such as a decision-making framework and decision-making tools are developed by NMBA to guide nurses in making decisions about their scope of practice. RNs should be accountable for any decisions they make in their nursing practice and should be able to justify their decisions based on the code of ethics and professional conduct, evidence-based practice, policies and procedures of the workplace setting.

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Communication can be a complicated process, sending or receiving incorrect messages always exists. The more skilled your writing ability is, the more accurate your communication becomes. A written paper then becomes complete, practical and successful; and when a nurse is at this stage of their writing, the documentation will be perceived and valued as something credible. Writing in nursing, compared to being an author for example, is a minimal yet crucial part of being a nurse. Nurses are liable for their word, even mistaking a single word can lead to

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On the other hand, issue related to nursing documentation are such as illegible nursing documentation, misspelled words and poor grammar. Sometimes, nurses’ records can be confusing, intriguing, and sometimes downright comical. Grammar and syntax problems are frequently at the heart of documentation bloopers. Thus, a clear, concise documentation is very important. The nurse educators should emphasize the importance of proper grammar and syntax in documentation, and instruct nurses to cross-check their notes with another healthcare professional if they suspect their entry is

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Substantial ethical and legal considerations arise when contemplating the possibility that Nurse X might neglect the required observations on the patient and instead compose false observations into their medical record. The activities of Nurse X have not only fragmented the fall policy of the assisted living home where she works but also the ethical and legal regulations that govern the nursing profession. In the following section, we will identify and discuss two significant components of the Code of Conduct and the Code of Ethics for Nurses that were not upheld in this case. Nurse X went against the standard of professional conduct, which is one of the major components of the Code of Conduct for Nurses. The Australia Nursing and Midwifery Board establishes the criteria for ethical and competent behaviour that nurses are compelled to comply with in their professional practice (Nursing and Midwifery Board Australia, 2018).

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Provision three is to protect the health, safety, and rights of the patient. I have seen this provision greatly applied to my nursing experience in clinical to provide; privacy, confidentiality, protection of patients in research, standards and review mechanisms, acting on questionable practice and addressing impaired practice. Privacy and confidentiality go close together. Remove identifiers before leaving the clinical floor, don't discuss loudly to others about patient care, respect the patient by only informing those needed about the patient and be considerate to boundaries/privacy when providing care. As a nurse we are the patient's advocate and are required to keep what is shared confidential, unless if it puts risk to the patient or

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An Enrolled Nurse registration is dependent on adhering to the competency standards which the Enrolled Nurse is assessed by to retain a current registration. One of the standards that governs the Enrolled Nurses practice is standard 3 ‘Conducts nursing practice in a way that respects the rights of individuals and groups’ (NMBA, 2002). This includes caring for patients in a health setting at a time when the patient is in a vulnerable state, a lot of person information is shared with all the nursing staff and medical staff. As an Enrolled Nurse the patient’s right to confidentiality must be protected including all medical records from any unauthorised public members. This required action on the Enrolled Nurse’s part is also required by the Code

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Ragan, Ronald. Brandt, Julie. Tregnago, Megan. (2012) Joint commission survey results revealed a need for improvement at the floor level in nurse to patient communication.

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According to Patterson & Krouse (2015), It is important to transfer the message in a good way, for that the communication skills is one of the most important basic skills of nursing leadership. More than that, communication in nursing can make their job efficiently and help them to communicate with a wide range of people, including the patient, patient 's family, and healthcare providers. However, unlike bad communication, which increases nursing staff problem and can lead to worsening the patient health condition, a good communication saves time and reduces the problem of nursing staff in resaving and deliver the right information. Furthermore, communication is not only talking with the patient it’s also listening to what the patient 's family and healthcare providers are saying to collect more information that helps the nurses to save lives. In this paper, I will reflect my communication that goes well with one patient.

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A nurse must keep up to date on education and new processes in health-care, so they can provide the best care. As a nurse, you have promised to give each of your patients the best care that can possibly be given. Nurses must follow a code of ethics, to act safely, provide ethical care no matter how they feel about the patient or the reason they are in your care. Following this code of ethics shows your commitment to caring for people and society, it is a guide of ethics and standards to follow to keep everyone safe. Nursing is also a wonderful opportunity to meet hundreds of people from almost every nationality and every walk of life.

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