Record-Keeping in Nursing: Principles and Best Practices Case Study

Impact of Effective Record-Keeping on Patient Care Quality

Key principles surrounding record-keeping in contemporary nursing

Professional principles which are set out in guidance provided by the Nursing and Midwifery Council

The principle of good record keeping by NMC is applicable for all types of records regardless of their form and the way they are stored, which can include different sources of information. This can include the presence of handwritten cynical notes from the physician alongside emails as well as latest to and from other Healthcare professionals and laboratory reports (Green and Chan, 2022). This is followed by the presence of extra reports as well as printouts from monitoring equipment, incident reports and statements along with photographs, video, tape recording of telephone conversation and text messages. The primary principle of a good record keeping by NMC also relies on legible handwriting, sign entries of record and including person’s , job title and first anti in case of written record. In line with local policy, the inclusion of date and time on all the records in a chronological order and keeping it close to the actual time alongside clear and accurate recordings (Nmc.org.uk, 2023). This also includes using professional judgement, factual abbreviation and undertaking reviews in order to provide clear evidence of arrangement for the future reference on care and treatment. Besides, identifying risks and problems on record and following them with proper action while managing the duty of communication with colleagues to ensure the storing of all information in regards to the care process is important during record keeping (Muppet.pbworks, 2023). On the other hand, using an easy language and involving careers to maintain the overall record creeping process and keeping the photocopies scans for the future reference.

Identify legal issues relating to record-keeping

The legal issues in regards to the record keeping refers to addressing complaints or legal processes alongside awareness of legal requirements and guidance in regards to the maintenance of confidentiality while record keeping (Creighton et al. 2022). This is followed by ensuring the overall care practice by contemporary nurses in line with National and local policies such as "NHS information governance guidance on legal and professional obligation 2007" and "The Data Protection Act 1998" (Muppet.pbworks, 2023). It also includes awareness of rules of governing parties in terms of respecting confidentiality of the supply and using the information for secondary purposes by following local policy and guidelines with the aim of avoiding legal breaching.

Provide a range of record-keeping examples

The NMC highlights different types of record in the care aspects and these are not limited to the service user’s context. There are several forms of record keeping records and this can be included in the form of emails as well as incident reports alongside videos, photographs, text messages, tape recording of telephone conversations and many more (Adler et al. 2022). However, the primary principle of this record keeping includes the golden rules of legible handwriting while keeping those records in nursing. On the other hand, the primary way of keeping records for the nurses and midwife are generally set by their employers and by the use of NMC guideline, nursing staff and midwives r capable of using different methods for keeping record safe (Creighton, 2022). However, the primary principle of a good breakfast refers to the well establishment and reflects the core values of individuality as well as the partnership working in contemporary nursing.

While good record keeping is considered an integral part of nursing and midwifery practices, it also helps with addressing the provision of safe and effective patient care on the basis of the circumstances (Parmar et al. 2022). Even though the national programs for the implementation of information communication technology as well as electronic record keeping are introduced in the UK with the evolving of electronic record keeping for the nursing staff, the use of paper waste records are commonly managed here and the guideline of NMC applies for both paper and electronic records (McGrath et al. 2017).

Verbal record keeping

The concept of verbal record keeping refers to the direct conversation between the clinical personnel alongside the patient or the family member (Taylor, 2023) while exchanging verbal words on keeping patient information and keeping those records either by using paper or electronic process. The verbal record keeping also consists of verbal concerns from the patient in terms of a green or declining the proposed nursing activities in the form of speech while sharing information. It sometimes uses written consent in the form of a signature while exchanging information and keeping the record for future reference (Anbro et al. 2020).

Non-verbal record keeping

Before the adoption of electronic record keeping, nurses were responsible for documenting the importance of nonverbal communication in the medical interview to access the source of information. This type of record keeping relies on the patient's satisfaction, patient recall for medical information and compliance with keeping appointments as well as complaints with the medical regiment in the health care setting (Díaz-Agea et al. 2022). This is also associated between the physicians and the patients by indirect facial orientation without disclosing patient information in public. This process also helps by providing emotional support and neglect of the active environment in the conversation while remembering the small details in regards to the patient and accessing significance of components of the communication which is considered a reliable source for keeping medical records (Shorey and Wong, 2021).

Electronic record keeping

The use of electronic medical records is considered a computer system that helps nursing staff to store organised and retrieving medical information in regards to the patient (McCarthy et al. 2019). This form is considered to be shown as more understandable and fully legalised in comparison with paper records and can be printed out for the patient while reducing medical error associated with the difficulties of reading handwriting prescriptions. The primary advantage of using this record keeping benefits the nursing staff to spend on screen time and reducing the overall time for professionals to adopt practice guidelines and sharing medical information among multiple specialists to improve the overall treatment process for the same patient (McCarthy et al. 2019). This record keeping is also considered a positive financial setup on investment for the Healthcare organisations. This type of record keeping holds enormous promises with the aim of improving the overall quality of healthcare and having an open space while retrieving information in regards to the patient (Perry et al. 2019). It also provides a proper use of compulsory fields in the form of reasons for clinic and visit alongside the reason for prescribing specific medication for the doses which help with maintaining accuracy and completeness of the medical information.

How does record-keeping impact the development of a therapeutic relationship?

Holistic/individualised care

Keeping record is considered a significant part of the holistic nursing care of the patients while promoting a better communication process as well as the maintenance of continuity and consistency. This is followed by managing efficiency and reinforcing professionalism while maintaining care aspects in hospital settings. Medical records also establish the proof of provided treatment by the medical professionals in the hospital setting while justifying the implementation of right treatment (Molina-Mula and Gallo-Estrada, 2020). It also helps with capturing the reality of events in medical fields along with delivering care and implying legal regulation in the medical care setting. It also helps with maintaining respect for the patient’s preferences as well as preserving the patient’s dignity (Enlow et al. 2019). This factor helps with managing patient-centred care on the basis of the mutual understanding of physical, psychological along with emotional and spiritual dimensions without affecting their overall healthcare journey. The holistic approach is considered rooted by understanding every aspect and dimension with the aim of improving the overall health outcome of the patients.

Family-Centred Care

The use of electronic health records in the form of patient portal has patient entered approaches while allowing the patient to interact with the clinical professionals and managing their own health care and information which improve the patient and clinic experience while delivering a family centred care (Ekberg et al. 2021). The linking capacity of medical record between siblings and the members of the households provides opportunity while carrying along with their own implications of medical record which has them to explore the opportunities and effectiveness of family centred care aspects and providing support to the patient while keeping record of others who have familial relationship with the patients.

NHS values

The improvement in record keeping ensures basic possible care aspects for the patient on the basis of 6 values in the NHS constitution while working together for the patient. It also maintains respect and dignity alongside commitment to the quality of care for the nursing staff and accounting factual records on patient information during the delivery of care under the NHS services. It also helps with the NHS values of improving not just the health of the patient, but also their overall life by keeping their medical information for the future references (Alageel and Gulliford, 2019).

Professional behaviours

The primary four principles by NMC refer to prioritising people along with practising the care process effectively as well as preserving safety and the promotion of professionalism and trust of nursing staff during the care aspects (Mlambo et al. 2021). However, it also includes keeping records and reports as part of the responsibilities of nursing administration under safe custody while managing their services alongside the care load and patient care activities which shows their professionalism. This also includes managing ethical and legal implications by maintaining confidentiality of records.

References

Adler, H., Gould, S., Hine, P., Snell, L.B., Wong, W., Houlihan, C.F., Osborne, J.C., Rampling, T., Beadsworth, M.B., Duncan, C.J. and Dunning, J., 2022. Clinical features and management of human monkeypox: a retrospective observational study in the UK. The Lancet Infectious Diseases, 22(8), pp.1153-1162.

Alageel, S. and Gulliford, M.C., 2019. Health checks and cardiovascular risk factor values over six years’ follow-up: Matched cohort study using electronic health records in England. PLoS medicine, 16(7), p.e1002863.

Anbro, S.J., Szarko, A.J., Houmanfar, R.A., Maraccini, A.M., Crosswell, L.H., Harris, F.C., Rebaleati, M. and Starmer, L., 2020. Using virtual simulations to assess situational awareness and communication in medical and nursing education: A technical feasibility study. Journal of Organizational Behavior Management, 40(1-2), pp.129-139.

Creighton, L., Devlin, N., Blair, J. and Smart, A., 2022. Professionalism in nursing 4: Record keeping, consent and capacity. Nursing Times [online], 118(7).

Creighton. L., 2022., “Professionalism in nursing” Available at: https://www.nursingtimes.net/clinical-archive/patient-safety/professionalism-in-nursing-4-record-keeping-consent-and-capacity-13-06-2022/ [Accessed on 26th May 2023]

Díaz-Agea, J.L., Orcajada-Muñoz, I., Leal-Costa, C., Adánez-Martínez, M.G., De Souza Oliveira, A.C. and Rojo-Rojo, A., 2022, February. How did the pandemic affect communication in clinical settings? A qualitative study with critical and emergency care nurses. In Healthcare (Vol. 10, No. 2, p. 373). MDPI.

Ekberg, K., Timmer, B., Schuetz, S. and Hickson, L., 2021. Use of the Behaviour Change Wheel to design an intervention to improve the implementation of family-centred care in adult audiology services. International Journal of Audiology, 60(sup2), pp.20-29.

Enlow, P.T., McWhorter, L.G., Genuario, K. and Davis, A., 2019. Supervisor–supervisee interactions: The importance of the supervisory working alliance. Training and Education in Professional Psychology, 13(3), p.206.

Green, A. and Chan, S., 2022. Report to the Nursing and Midwifery Council on Language Testing Policy. Nursing and Midwifery Council.

McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett?Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M. and Savage, E., 2019. Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of nursing management, 27(3), pp.491-501.

McGrath, J.M., Arar, N.H. and Pugh, J.A., 2017. The influence of electronic medical record usage on nonverbal communication in the medical interview. Health informatics journal, 13(2), pp.105-118.

Mlambo, M., Silén, C. and McGrath, C., 2021. Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature. BMC nursing, 20, pp.1-13.

Molina-Mula, J. and Gallo-Estrada, J., 2020. Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. International journal of environmental research and public health, 17(3), p.835.

Muppet.pbworks. 2023., “Record keeping: Guidance for nurses and midwives” Available at: http://muppet.pbworks.com/f/NMC+guidelines+for+recordkeeping.pdf [Accessed on 26th May 2023]

Nmc.org.uk. 2023., “Guiding and supporting information.” Available at: https://www.nmc.org.uk/standards/guidance/ [Accessed on 26th May 2023]

Parmar, P., Ryu, J., Pandya, S., Sedoc, J. and Agarwal, S., 2022. Health-focused conversational agents in person-centered care: a review of apps. NPJ digital medicine, 5(1), p.21.

Perry, A.G.G., Potter, P.A. and Ostendorf, W., 2019. Nursing Interventions & Clinical Skills E-Book. Elsevier Health Sciences.

Shorey, S. and Wong, P.Z.E., 2021. A qualitative systematic review on nurses’ experiences of workplace bullying and implications for nursing practice. Journal of Advanced Nursing, 77(11), pp.4306-4320.

Taylor, H., 2023. An exploration of the factors that affect nurses' record keeping. British Journal of Nursing, 12(12), pp.751-758.