Significance Of Record Keeping In Contemporary Nursing

Significance Of Record Keeping In Contemporary Nursing

Introduction: Significance Of Record Keeping In Contemporary Nursing

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Record keeping in a comprehensive manner has been omnipotent in contemporary nursing. It plays a crucial role in scrutinizing the quality and accuracy of the care provided by the nurses to their respective care seekers. This study will cover every aspect related to the significance of record-keeping in contemporary nursing in order to have a coherent perspective.

Discussion on the significance of record keeping with respect to contemporary nursing

Record keeping is a method that helps in determining the actual condition of the care-seekers as well as recognizing any sudden changes in their health. Based on the views of McKeown et al. (2019), proper record-keeping in nursing can help even other care professionals to understand the condition of that person in the future resulting in mitigating their actual needs. There are some general principles regarding record keeping that need to be kept in mind while nursing or attending the care-seekers. 

Legible handwriting is among the professional principles regarding “good record keeping” provided by “the nursing and Midwifery Council UK” (Obsgynhandbook.nhsggc.org.uk, 2022). Along with that, "all entries to the records need to be signed", "firm and relevant judgments need to be in the records", and "any risks or problems must be enlisted” which can make a record-keeping process more effective and accurate. In the views of Gear, Koziol-McLain, and Eppel, (2021), communicating with other fellow professionals regarding the care seeker's details is important in mitigating the shift change hazards. In addition to that, any records about any hospitalized persons must not be violated or destroyed. A renowned article states that “documented decisions” such as the outcome of any disciplinary proceeding are considered to be one of the crucial components of keeping records in nursing (Nmc.org.uk, 2021). Based on these professional principles, record-keeping in contemporary nursing can be constructive resulting in contributing the best care to the care-seekers. Another study provides that “a nurse's obligation in the code” for keeping accurate, as well as clear records related to their practices, are set out by “The Nursing and Midwifery Council” (Independentnurse.co.uk, 2022). This clearly indicates that nurses need to abide by the principles in order to prepare proper records results in improving the quality of care towards their patients.

Proper record keeping in nursing is not only beneficial for the health seekers to have access to their own health records but also for the nurses to avoid any legal issues in the near future. Information from a recent study indicates that “inadequate medical record keeping” has endangered one general practitioner’s career (Expertwitnessjournal.co.uk, 2019). In addition to that, the study has also mentioned that she “was found to be in breach of duty” for avoiding “red flag symptoms” in the sufferer’s condition. Based on the views of Tajabadi et al. (2020), nurses often skip valuable information while keeping records in nursing due to inadequate time. This particular factor can be enough to make the practitioners face legal issues like the case mentioned above. 

Poor quality of documentation is considered to be providing poor standard nursing care to the patients. In the highlights of Nittari et al. (2020), record keeping is a vital part of nursing practices that has substantial legal significance. One of the most common mistakes that nurses make while documenting the care seeker's information is poor maintenance of confidentiality. A renowned article indicates that a nurse from West Wales in the UK has been allegedly as well as sacked on the basis of breaching patients’ confidentiality (Bbc.com, 2022). In order to mitigate this legal issue, a nurse needs to take care of the personal information regarding each of their respective care-seekers while keeping records. Hence, it is established that “proper record keeping in contemporary nursing” while following all the terms as well as professional principles is crucial. Based on this factor, nurses not only are able to provide the best care to their respective patients but also avoid legal issues in an appropriate manner. 

Record keeping procedure helps in recognizing patients’ conditions which results in serving them the way they need. There are three ways that can bring improvement in the documentation process in nursing such as verbal, non-verbal, and electronic. 

Proper documentation of patients’ details includes assessment, implementation, evaluation as well planning of care. According to Erel et al. (2022), a variety of communication expertise assists nurses in understanding the genuine condition of the care-seekers in the most significant manner. Verbal recording keeping methods consist of building therapeutic relationships, assuring the comfort of the patients, and maintaining proper confidentiality while getting answers is useful for documenting their formation in an effective way. Based on the information collected from a recent study, it is acknowledged that effective communication as well as clarity in information exchange is important for patient safety and the quality of care (Rcseng.ac.uk, 2022). This particular method in return helps in effective “record-keeping in contemporary nursing”.

In order to provide the best care to the patients, “appropriate documentation of patients’ records” with explicit information is vital. In the views of Sugg et al. (2022), the non-verbal record-keeping method is considered to be an effective way to nurse a patient in an effective way. Care-seekers with serious conditions often are not able to communicate verbally results in encountering difficulties in understanding the patient's condition. In order to mitigate such problems non-verbal communication skills such as  “eye contact”, “shaking hands”, “smiling at them” as well as "being observant of their facial expressions" play a crucial role. Based on these factors, nurses can gather enough information regarding the care-seeker's condition that implicate an effective “record-keeping procedure”.  

Electronic methods regarding “patients’ record keeping” deliver enough data in order to recognize the required measures to nurse them in an appropriate manner. Based on the views of De Groot et al. (2019), electronic documentation methods are more effective than manual records. In addition to that, “electronic record-keeping measures” are far more easily accessible and fast compared to hand-written ones. This significant factor assists to minimise the efforts and maximise the productivity of the healthcare workspace as the nurses get to invest more time in taking care of the patients. To highlights of Rakemane and Serema (2018), electronic “record-keeping” includes e-mail messages, electronic spreadsheets, word-processed documents as well as digital images. This electronic method not only saves time but also makes the “record-keeping procedure” more exclusive and flawless.

Record keeping in an appropriate manner is considered to be an integral part in contemporary nursing as it assists in not only providing effective care but also safeguarding the patients' confidentiality. The impact of this significant procedure has a vast impact on the therapeutic relationships between the care providers and the care-seekers. 

Encouraging the patient for a speedy recovery, as well as inspiring self-care is one of the aspects of holistic care leading to building therapeutic relationships (Batstone, Bailey and Hallett, 2020). Along with that, individualized care for the care-seekers is fulfilling one's needs according to their requirements and it only depends upon the developed relationship between the nurses and the patients. This significant factor of building healthy as well as therapeutic relationships comes as a benefit of proper record-keeping in contemporary nursing as it enables the care provider to know more about the patients in the most proficient manner. 

Good and well-maintained record keeping in nursing also has a positive impact on providing family-centered care to the care-seekers. Based on the opinions of Utami and Natalia, (2021), many patients need to stay long in healthcare organizations for their treatment which tends to be home-sickness. In terms of keeping day-to-day updates of the patients, communicating with them on a regular basis as well as understanding their needs, and acting accordingly make them feel homely. In this way, proper documentation of the patient's reports leads to improvement in the patient-nurse relation in an effective way. 

Nurses need to abide by the NHS values in order to provide quality care to the patients as well as fulfill their duties accordingly. The NHS values talk about working collaboratively, prioritizing the care-seekers first, maintaining dignity, and showing respect to each of the patients resulting in helping to keep proper records. In addition to that, committing to deliver the best care, improving their lives, and delivering equal care to everyone depicts the NHS values which in turn assist in building therapeutic relationships (Nhsprofessionals.nhs.uk, 2022).  Proper record-keeping covers all the aspects of the NHS values as it only talks about a patient's condition, and required measures to initiate in order to pave the way for their speedy recovery. Professional behavior is interlinked with maintaining accuracy in the patient’s record-keeping procedure which leads to an impact on the purposeful relationships between the care providers and care-seekers. In order to analyze the patient's condition and document it in an appropriate manner, it facilitates the professional practice of the nurses as well as helps in improving their bonding with the patients. Record-keeping being a vital component in nursing, naturally develops therapeutic relationships through providing holistic and family care, abiding by the NHS values and maintaining professional behaviours significantly 

Conclusion

Thus, it can be concluded that maintaining valid and accurate record-keeping in contemporary nursing is one of the fundamental duties of the care-providers. Besides, it not only helps in recognizing and analysing the patient's condition but also prevents any lawsuits encountered by the nurses. Nonetheless, it can be determined that proper documentation of patient records by following principles and abiding by the required protocols helps in securing the lives of the patients as well as the reputation and career of the nurses proficiently. in the most proficient manner. 

Reference list

Batstone, E., Bailey, C. and Hallett, N., 2020. Spiritual care provision to end?of?life patients: A systematic literature review. Journal of Clinical Nursing, 29(19-20), pp.3609-3624.

Bbc.com, (2022).Nurse sacked for breaching patient confidentiality.Available at:https://www.bbc.com/news/uk-wales-south-west-wales-36735065[Accessed on:15.11.2022]

De Groot, K., Triemstra, M., Paans, W. and Francke, A.L., 2019. Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. Journal of advanced nursing, 75(7), pp.1379-1393.

Erel, H., Trayman, D., Levy, C., Manor, A., Mikulincer, M. and Zuckerman, O., 2022. Enhancing Emotional Support: The Effect of a Robotic Object on Human–Human Support Quality. International Journal of Social Robotics, 14(1), pp.257-276.

Expertwitnessjournal.co.uk, (2019).The Problems with Inadequate Medical Record Keeping.Available at:https://expertwitnessjournal.co.uk/medico-legal/1126-the-problems-with-inadequate-medical-record-keeping[Accessed on:15.11.2022]

Gear, C., Koziol-McLain, J. and Eppel, E., 2021. Engaging with uncertainty and complexity: A secondary Analysis of primary care responses to intimate partner violence. Global qualitative nursing research, 8, p.2333393621995164.

Independentnurse.co.uk, (2022).Accurate record keeping.Available at:https://www.independentnurse.co.uk/professional-article/accurate-record-keeping/117281/[Accessed on:16.11.2022]

McKeown, M., Thomson, G., Scholes, A., Jones, F., Baker, J., Downe, S., Price, O., Greenwood, P., Whittington, R. and Duxbury, J., 2019. “Catching your tail and firefighting”: The impact of staffing levels on restraint minimization efforts. Journal of psychiatric and mental health nursing, 26(5-6), pp.131-141.

Nhsprofessionals.nhs.uk, (2022).What are the NHS values?.Available at:https://www.nhsprofessionals.nhs.uk/nhs-staffing-pool-hub/working-in-healthcare/what-are-the-nhs-values[Accessed on:16.11.2022]

Nittari, G., Khuman, R., Baldoni, S., Pallotta, G., Battineni, G., Sirignano, A., Amenta, F. and Ricci, G., 2020. Telemedicine practice: review of the current ethical and legal challenges. Telemedicine and e-Health, 26(12), pp.1427-1437.

Nmc.org.uk, (2021).Keep records of all evidence and decisions.Available at:https://www.nmc.org.uk/employer-resource/local-investigation/guiding-principles/record-evidence-decisions/[Accessed on:15.11.2022]

Obsgynhandbook.nhsggc.org.uk, (2022).Record keeping: Guidance for nurses and midwives. Available at:https://obsgynhandbook.nhsggc.org.uk/media/1521/record-keeping-guidance-for-nurses-and-midwives.pdf [Accessed on:15.11.2022]

Rakemane, D. and Serema, B.C., 2018. Electronic records management practices at the Companies and Intellectual Property Authority in Gaborone, Botswana. Journal of the South African Society of Archivists, 51, pp.148-169.

Rcseng.ac.uk, (2022).3.1.1 Communication with patients.Available at:https://www.rcseng.ac.uk/standards-and-research/gsp/domain-3/3-1-1-communication-with-patients/[Accessed on:15.11.2022]

Sugg, H.V., Richards, D.A., Russell, A.M., Burnett, S., Cockcroft, E.J., Thompson Coon, J., Cruickshank, S., Doris, F.E., Hunt, H.A., Iles?Smith, H. and Kent, M., 2022. Nurses’ strategies for overcoming barriers to fundamental nursing care in patients with COVID?19 caused by infection with the SARS?COV?2 virus: Results from the ‘COVID?NURSE’survey. Journal of Advanced Nursing.

Tajabadi, A., Ahmadi, F., Sadooghi Asl, A. and Vaismoradi, M., 2020. Unsafe nursing documentation: A qualitative content analysis. Nursing ethics, 27(5), pp.1213-1224.

Utami, R.S. and Natalia, S., 2021, December. The Relationship of Therapeutic Communication with Inpatient Satisfaction. In Proceeding (pp. 105-112).