Discussing Principles And Importance Of Good Record Keeping Nursing Essay

Discussing Principles And Importance Of Good Record Keeping care for EssayThis essay aims to focus on indicate charge. It will briefly discuss the treat and Midwifery Council (2009) guidance for nurses and midwives and the importance of obedient degrade keeping in the wellness c be setting. This literature will to a fault discuss quartet of these normals. The prime(prenominal) principle is of detailed appraisal and reviews which tendings set up a divvy up plan. It then moves on to the next principle which discusses hand composing and how it should be indite legible. The next principle that has been discussed is the one that files should be accurate and book of accounted in a mode that meaning is clear. at last the last principle that has been discussed is that records should be existent and not include unnecessary abbreviations, jargon, meaningless phrases or irrelevant speculation. It then progressively moves on to discuss how these four principles impact on a fea r plan and how they atomic number 18 maintained.The Nursing and Midwifery Council (NMC 20091) have guidelines for unsloped record keeping, this helps nurses maintain good record keeping skills. Good record keeping skills is an important part of a nurses role in the health tutorship setting. It helps nurses provide the correct and safe lot towards a uncomplaining. Computer papersation is use in m whatsoever of the health bang settings, however hand writing in documentation is still widely utilise. The guidelines are used for both scripted and electronic record keeping.The process of record keeping is e very bit as important as hands on clinical skills to helping maintain patients recourse within the health business organization setting. It is not only important for monitoring a patients interference and checkup condition, it is also important for any legal issues that may arise when providing fretting to a patient regarding any bid or discourse they have received wh en in a health misgiving setting (Griffith 2007363 ).There is a principle in the NMC 2009 for good record keeping that states you should record details of any assessment and reviews undertaken and provide clear evidence of the arrangements you have made for future and ongoing attending. This should also include details of data given about anxiety and treatment (NMC 2009). This principle can help when putting a care plan in place for the care postulate of a patient. When a patient first comes into any health care setting the first form of documentation is a written assessment of the patient and what their care needs are. This is a very important part of record keeping as it is the beginning of the care planning process. Assessment forms will include vital schooling on the patients medical condition and what their care needs are. It is also important to have any information regarding next of kin in case a patients condition was to return (Miller and Gibb 2007250). A part of an assessment that is vital to a patients safety can be information regarding any medication. This can highlight what a patient may be taking at the present clock time or any medication that they have an every last(predicate)ergy to. If information regarding each(prenominal)ergies is understandably authenticated then all care staff involved are aware when delivering care to the patient (Diamond 2005460). The next stage in the care planning process is to put a plan into action to what treatment is best for the patients needs. All aspects of the patients care needs get reviewed so that all the patients care needs can be met. carrying out moves on from the planning stage in a care plan. This stage involves the nurse in charge of the patient getting referrals from early(a) care professionals to equip the care needs of the patient.Evaluation is the final part of a care plan which looks at all the information recorded in a care plan. If the care needs of the patient have not been met then the health care professionals are capable to make changes to the care plan for the best beguile of the patient. This may include professionals at a different skill level, specificaly to deliver that care and treatment. It is the health care professionals responsibility to record and review all information regarding patients care. This enables care progress and makes sure the patients care needs are universe met safely (Brooker and Waugh 2007 358).One of the principles for good record keeping is regarding handwriting hand writing should be legible (NMC 2009). A way in which badly written documents can cause problems is if prescribed medication that has been recorded is not written clearly, not only the type of medication but also information on administering medication. If a patients records are written clearly there is less risk to the patients safety (Reddy 2006330). In any care setting good writing skills are very important as other multidisciplinary teams can be involved i n a patients care. It is important that they can easily read any treatment and care a patient is receiving and that all needs of the patient are being met. A care plan is a legal document so it is vital that all information can be easily read.Any care professional who pens any information in a care plan is personally responsible for the information that they have written (Powell 2009300).When a nurse writes in a care plan regarding treatment to a patient they may make a mistake and need to correct what they have written, this is the only moderateness wherefore information can be changed. Correction fluid should never be used in a care plan to cover any written mistake. A line should be put finished the error that has been made and the appropriate notes should be written in. The person making the change to the care plan should sign and date when they made the correction so other health care professionals can see why the correction was made to the care plan (Diamond 2005261). Thi s makes all written information in a patients or clients care plan more easily to read and any individual who writes in the care notes should try and use a black ink pen on white paper. A patients care plan is the main tool used in a care setting to give-up the ghost with different care professionals and services who may be involved in the care of a patient. In a variety of different care settings different coloured paper is used for certain medical interventions. It is important that any paper and ink that is used in a care plan can be easily photocopied, as at times copies of some of the patients care plans may be inevitable (Griffith 2004123).There is also a principle in the NMC that states your records should be accurate and recorded in a way that the meaning is clear. All notes that are written about a patients care should be clear so that any other care professionals who need to read the care plan know and sympathize what has been written. If a nurse was to write settled da y what meaning does that actually have to other care staff. Care plans are helpful at conclusion out any care issues a patient may have. If there has been a problem regarding a patients care and it has been resolved then this has to be clearly documented. When a nurse comes on shift and takes over the care of a patient and the patients care notes may read awake most of the night delinquent to being in pain and then did not write how she helped the patient overcome this problem then this is poor record keeping skills. Highlighting every intervention while delivering care is vital and information should not be missed out. It may be the case that the patient received pain sculptural relief medication at the end of that previous nurses shift. If this was not documented in the patients care notes or kardex then the nurse who has taken over care of the patient may administer pain relief again, putting the patients safety risk. Documenting and recording clear and meaningful information regarding a patients care and any changes in a patients condition is a skill, and it is essential care professional in a care setting get it right. All written and computerised notes should be spelt accurately and have a clear meaning. Spelling may not constantly put a patients safety at risk but its not always that way regarding miss spelt medication. Many medications do sound the same when you say them but they are spelt differently and this can put a patients safety at risk (Diamond 2005568).To keep records accurate all information written in a patients care plan must have a date with the day, month and year the staff member who has documented the information in the care plan. The time of documentation should also be added using the 24 hour clock. If all information in a patients care plan is accurate and up to date it helps maintain good communication between all care professionals involved in the patients care (Griffith 2004124).Moving on to another principle in the NMC for ma intaining good record keeping is the one that states records should be factual and not include unnecessary abbreviations, jargon, meaningless phrases or irrelevant speculation. One way this can cause a problem is if a nurse were to write in a patients care notes using abbreviations or jargon. Nurses who come on to a shift to take over the care of patients have to be able understand what has been written to help them deliver care effectively. Records are an important part of a patients care in which various health care professionals are involved in. Using abbreviations or jargon can put a patients safety at risk as it may have a all told different meaning to another person (Brooker and Waugh 2007154).The NMC try to advice health care staff not to use abbreviations and follow the principles for record keeping. In some health care settings abbreviations will be used and nursing students need to be aware of what they mean to avoid any confusion. One of the abbreviations that are used safely in a health care setting is BP which means blood pressure. Abbreviations get used in health care settings to try and save time on record keeping as it does take up a lot of the health care staffs time (Diamond 2005665). When care professionals follow these four principles of good record keeping it has an impact on a patients care plan in some(prenominal) ways. A care plan has all the relevant information regarding a patient. Having the correct and up to date information regarding a patient helps maintain a patients safety. Good record keeping has an impact on a patients health and helps recognise any sudden changes in a patient condition. If all information is written clearly with the correct spelling then other care professionals involved in the care of the patient can clearly understand what has been written. A well documented care plan helps maintain good communication between all care staff involved in the care of the patient. Some care staff who are involved in the pati ents care never see each other and a care plan is the only tool they have and would use for communicating and knowing what treatment and care the patient has been given and what care still needs to be delivered to the patient (Greyer 200524). A care plan is a legal document and all written information has to be accurate, clearly written and should not have any jargon or abbreviations contained in it. If a care plan is clearly documented with all the relevant information it impacts on the healthcare staff by safe guarding them in regards to any legal issues involving patients including the care staffs involvement (Diamond 2008119).A care plan is maintained by reviewing this document at regular intervals. Reviewing care plans helps maintain accurate and safe care towards a patient. The main purpose for reviewing care plans is to maintain continuity of care. A review will help care staff determine if all care needs of the patient are being met and to notice if any of the care needs of the patient have changed from the initial assessment (Miller and Gibb 2007272). An audit is another way to help maintain good record keeping of a care plan. An audit will check that all information is written clearly, with meaning, up to date and its accuracy. Audits can help highlight any inaccurate documentation and changes that can be made to rectify the inaccuracies within a document (Anderson 2000355).Throughout this essay record keeping has been discussed and the importance of record keeping in the health care setting. It looked at the Nursing and Midwifery Council (2009) guidance for nurses and midwives and four principles of record keeping. It later discussed how these principles impact and are maintained in a care plan. Record keeping is an important skill that nurses should have to maintain good communication between other care staff members regarding care needs of a patient. All care professionals involved in the care needs of a patient may never meet and only communicate through what they write in a patients care plan. It is important that all information is written clearly and can be easily understood to help maintain continuity of care towards the patient. There could be a problem for some nurses when it comes to writing information in a patients care notes. One way of doing this is if a nurse comes from another country and English is not their first language then they might have some difficulty writing care notes and they need to be assessed to see if they are capable to write up notes correctly. Writing up care notes regarding a patient does take up time, many nurses feel the time used documenting information could be time used to treat a patient, but care plans are very important in the health care setting. Nurses should try and not leave writing up care notes to near the end of their shift, they should try and set aside time to document all relevant information regarding care given and nursing interventions of patient. If nurses leave writing up care notes to near the end of their shift and rush through what they are recording then this may cause them to miss out important information and could put a patients safety at risk. A care plan is a legal document and nurses should be aware of this when writing any care or treatment in a patients care notes. If all care notes are written clearly with no jargon then all other care professionals can easily read what the care needs are of the patient. Student nurses should be aware that good record keeping is a skill and it is every bit as important as clinical skills they will learn. If a nurse finds it difficult to read any information in a care plan, they should inform the person in charge. Care notes are vitally important to protect healthcare staff in the event of any legal allegations that a patient has made regarding care or treatment they have received from the nurse. A care plan is a very important document for a variety of different reasons so good record keeping is impo rtant in all health care settings.Anderson E (2000) Issues surrounding record keeping in district nursing practice. 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