Principles of Record Keeping

Principles of Record Keeping

Record keeping is an integral activity in many fields such as management, finance, health, and operation monitoring, to mention a few. It is paramount to keep accurate information that reflects a particular phenomenon. The ultimate target is to ensure that you have a factual record for future reference. Nurses have been subjected to a heighten in scrutiny concerning how they keep and maintain records. The field is governed by regulations such as the Human Rights Act 1998, which has increased the concerns over nature and access to health records. On the other hand, patients are increasingly motivated to evaluate and monitor the care offered (Daries et al., 2014). The complaints raised against health care practitioners can be settled either in or out of court.

Nonetheless, it is prudent to maintain comprehensive records. Thereby, health practitioners must meet all the essential legal stipulations and excellent record-keeping practices. The advice raised by the Code of Professional Conduct holds that effective note-taking is a crucial tool used for internal communication by nurses. The code states that nurses must warranty that the health record for an individual patient has accuracy in accounting for treatment, service delivery, and care planning (Daries et al., 2014). Therefore, it should be kept while involving the client in case it is applicable and completed in the wake of the event’s occurrence. In turn, the records should offer a clear proof of the planned care strategy, the decisions therein, what has been done and the information that was shared by the involved parties.

Principles of Record Keeping

Various principles guide record keeping in nursing. Records entries can be made by writing in hand or electronic systems. Despite the method adopted, the principles can be generalized by stating that whatever data is recorded ought to be accurate, genuine, and abide by patient confidentiality. Thus, if a nursing practitioner abides by the principles, they will come up with a valuable record-keeping technique (Montague, & Asan, 2014). The concise list below holds the fundamentals of the record-keeping principles.

• You should make a legibly written record or ensure correct keying into computer systems.
• The entries should have a signature.
• Ensure that the records are accurately dated with the timing close to the real-time of the events to the highest level possible.
• A nurse should make an accurate and precise entry of the events while keeping in mind that the patient may want to view the records at a certain point. Consequently, the file must be in a language that is understandable to the client.
• It is paramount to focus on facts rather than speculation.
• It is advisable to keep abbreviations to the minimum. For illustration, the nursing care system uses a wide range of acronyms, but not all spheres apply the same definitions; for example, DNA terms deoxyribonucleic acid. At the same time, in some instances, it means “Did Not Attend”, that is a patient failed to attend an individual appointment. Therefore, a nurse should avoid abbreviations to the level best (Hoglend, 2014).
• Maintain a record of the client’s contribution to their care by entering any information that he or she thinks is substantial.core risk written. In case changes must be done, ensure that you lay a line of distinction through the amendment while impending signatures while dating the changes.
• Never make an insulting or derogatory record about a client or colleague.

While keeping and maintaining the records, it is paramount to abide by the above principles. Moreover, if you land on the information you think is substantial while working with a patient, your initial task is to make a report to the registered practitioner who is in charge before considering entering it in the client’s record. It is paramount first to make a report and record later.

On the other hand, effective communication influences the quality of record keeping. In the course of abiding by the principles, efficient communication helps create good relationships, while safeguarding that the information is passed and comprehended in a bid to enhance the quality of life. Prevalently, excellent communication is hindered by various barriers. This often results in resentments, misconceptions, disappointments, and can demoralize not only the client but also the health care staff involved (Montague, & Asan, 2014). The principles discussed above underpin effective communication. Thus, nurses should be fully aware of the various communication barriers. In turn, with a good comprehension of the hindrances, the nursing personnel should develop countermeasures to overcome the obstacles.

Examples of Record-Keeping Methods

There are various means used to keep records in the health care set up. The diversity employed depends on the method employed by multiple workplaces. Some nursing centres use handwritten documents, while others have advanced to electronic or computer-based systems. Commonly, most workplaces use a combination of both written and electronic systems. As a nursing practitioner, you are required to abide by the various requirements and instructions set by the employer regarding record keeping despite the method utilized (Hoglend, 2014). The data used for record-keeping can be passed verbally, such as during a consultation appointment or while discussing the approach to be taken by colleagues. Thus, the orally given information must be accurately put into the record. Voice recording gadgets can come in handy in capturing the actual information passed. The shortlist below holds the various guidelines for using either computer-based or handwritten records.

• Know using the tools and information systems at the workplace.
• It is critical to protect and avoid sharing any passwords or smartcards issues to provide you with access to the systems with anyone.
• Ensure that the written records are not left unsecured in areas that can be accessed by unauthorized parties while any electronic system must be protected after you have signed out.

The principles of keeping records in contemporary nursing as aforementioned have a focal point in the dire need to ensure that patients’ confidentiality is upheld. Thereby, the laws must be held to safeguard the well-being of the patient irrespective of the strategy adopted by the workplace.

Impact of Record-Keeping in a Therapeutic Relationship

Practising nurses must fashion the record-keeping methods at hand in line with their setting, nature of practice while meeting the specifications of the population under treatment. Nursing records document the form, delivery technique, progress and results of the service offered, which influences the therapeutic association. The files at hand foster the coordination of health care and the process of shifting to advanced levels of care such as termination or referral (Hoglend, 2014). The accuracy of records can be supportive of a clinician while resolving disputes on matters like the quality of services offered, treatment improvement, and charges agreements. Other parties who handle record-keeping such as other employees in the department should be trained to maintain the confidentiality of clients’ information at a similar level of health care.

An accurately written record that entails all the essential attributes of patient treatment and monitoring is crucial not only because it creates an integral entity of providing care and managing the nursing practice but also as it contributes to the passing of vital information among the various parties that take part in offering the patients’ treatment and care. In a legal aspect, record keeping and documentation is also a backbone to protecting the nurse or health care practitioner (Ethical Standards & Practice Guidelines for Assessment, Therapy, Counseling, & Forensic Practice, 2014). A record that is well kept and maintained serves as a defence when a legal justification of any actions taken is needed. Moreover, useful documentation additionally, documentation safeguards the issue of professionalism and is evidence of the evolution of practices.

The list below holds the various benefits of maintaining a good record in the therapeutic relationship.

• Proper maintenance of records ensures that the continuity of care is simplified.
• It helps enhance effective communication and passing of suitable information among all the parties in the creation of a skilled professional team.
• It comes in handy in addressing the legal stipulations and arising complaints.
• It supports research, clinical audits, performance arrangement, and the allocation of available resources.
• It facilitates the identification of threats and helps to detect complications in due time.
• It promotes patient’s care provision with a patient-based approach to communication.
• The effectiveness of the clinical judgement depends on the records at hand.
• It enhances proper service delivery which influences the therapeutic relationship.
• It promotes accountability in the patient-nurse relationship.
• It supports that the choices were made concerning supporting the patient’s quality of life (Montague & Asan, 2014).

Conclusion

In summary, the records on patients’ health and progress are usually needed as evidence in a court of law or the investigation of a complaint at both local and organizational levels. At times, the records can be called for by professional governing bodies while analyzing the claims concerning any reported misconduct. Thus, as a nurse, you must record accurately while protecting the accounts. Not only will a health practitioner be required to explain the records in case of a complaint, but a registered practitioner also has a professional, ethical, and legal duty of care bestowed on them.