Importance Of Record Keeping

ROLE OF RECORD KEEPING IN NURSING PRACTICE

Introduction Clinical record keeping is an essential fragment of high class treatment and care and all nursing professionals have an obligation to record precise information about the care they are giving. According to Beach and Oates (2014) the relationship between the nurse and patient is changing rapidly and this will result in the way nursing staff record everything. The main reasons for keeping the records are to create a complete record of the patient in the services and to enable the continuity of care for that patient. The purpose of this essay is to explain the importance of good record keeping in nursing practice.

When writing the records, the nurse should always think about the continuity of care for the patients. That means, all the written records should be legible, dated, in sequential order and record everything immediately after care given. Do not record anything on behalf of someone else and maintain a regular audit about the data written. Student nurses should be working under the supervision of a qualified nurse. Prideaux (2011) states that good quality record keeping is directly linked with good nursing care, while poor quality of documentation connected to poor patient care. Good standards of record keeping will improve the patient care. Record keeping has legal importance. Hence all the records should be accurate and up to date. Moreover, it should be legible and should be in chronological order. All entries in record books will be dated and signed by the nurses immediately after the care. Because of the busy nature of work, nurses can use abbreviations from the approved list only. All the written data should be kept in a single place about a patient and should be monitored in regular intervals. Nurses should never record anything on behalf of someone else. When an adverse event comes up everything is legal documents and if proper documentation

Edwards (2009) argues that the patient will lose the confidence in health system, if their confidentiality is not respected. During an examination, the patient is providing their all personal details to the nurse in charge and it is the nurse’s responsibility to respect it. Confidentiality should be maintained for all data unless the patient safety has been compromised or a crime committed. The Code of Professional Conduct and Ethics for Registered Nurses and Midwives (2014) states that the nurse’s role in confidentiality range from using social media to all kinds of information technologies. Most of the health care settings are changing from hand written records to electronic reports and the nurses should know the basics before going online. All the records should keep in a single place and if they have any concern regarding the safety, the nurse should contact the local personnel