Record Keeping

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My aim for this annotation is to show my understanding of Record keeping. I will show an understanding of the duties of the registered nurse in relation to record keeping, show awareness of the professional and legal implications and understand the role of the student nurse in relation to record keeping. Record keeping is an important part of nursing and midwifery practice and is used as a vital tool in giving effective care. It is not an optional tool as it may put the patient at risk for example it allows other nurses and doctors to have information of a patients that are in service of care. Under code one of record keeping (NMC 2009) when record keeping it must be clear and accurate and they have to be completed as soon as possible. There are several positive outcomes by keeping records clear and accurate such as high standards of clinical care which includes satisfactorily assessing the patient's conditions, taking account of the patient's views and where necessary examining the patient. Continuity of care is also a positive outcome and Records should identify any risks or problems that have arisen and show the action taken to deal with them. It will promote good team work as it enhances better communication which makes it easier to pass on information within the health team. Confidentiality may be breached if not careful for example people in your care should not be discussed in places where information might be overheard. Nor should records be left carelessly, either on paper or on computer screens where they might be seen by unauthorised staff or members of the public. With these positive outcomes follows Quality issues such as the rate of professional practice is given at a high standard, it shows how skilled and safe the healthcare team is and works at and shows good team work. Records may include handwritten clinical notes, emails, letters to and from other health professionals, laboratory reports, x-rays, printouts from monitoring equipment,...
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