Effective Record Keeping in Nursing

The good record keeping in nursing is established through teamwork and it is regarded as an essential tool for establishing high-quality healthcare and reinforcing professional conduct in nursing (Haworth et al. 2016). For those seeking additional support, nursing dissertation help can offer valuable guidance on maintaining accurate and comprehensive records. The key principles to be followed in record-keeping within the nursing field are accountability, protection, transparency, compliance, retention, accessibility, disposition and integrity (Patience et al. 2016)

The Code of Professional Conduct developed by the Nursing and Midwifery Council mentions that proper note-keeping of the care provided to the patients acts to establish effective communication between nurses (NMC, 2019). This is because by consulting with the notes the nurses can understand what nature of care is already been delivered to the patients and what further care is required in turn helping to avoid duplication of care. The Code by NMC informs that recording the care of the patient is to be done with their active involvement and is to be completed as early as possible after the care is been given to avoid delay (NMC, 2019). This is because taking time in recording data for patient care may lead to create mistake in the recording of information as a result of forgetfulness of the fact. Moreover, patients are to be involved in recording data so that they are able to know as well as get involved regarding their personal care data is to be stored and used for future (Rabelo‐Silva et al. 2017).

The benefit of recording keeping in nursing is that it promotes evidence-based practice. This is because the records can be used by nurses as referrals to determine how effective care may be or the nature of actions regarding be taken for resolving mistakes in delivering care to particular patients who have similar health issues like the patient whose record is being referred (Jung and Kim, 2016). The proper recording keeping in nursing is essential as it helps in executing clinical audits and develops reports regarding the success of any clinical activity (Stevens and Pickering, 2010). Thus, it contributes to nursing research and performance data for monitoring the improvement in care service delivery.

References

Haworth, S., Bates, A.S., Beech, A. and Knepil, G., 2016. Quality improvement in documentation for patients with suspected facial fractures: use of a structured record keeping tool. Emerg Med J, 33(4), pp.268-272.

Jung, D. and Kim, J.H., 2016. Effects of a sexual health care nursing record on the attitudes and practice of oncology nurses. Sexual & Reproductive Healthcare, 9, pp.21-26.

Patience, N.T., Sibiya, M.N. and Gwele, N.S., 2016. Evidence of application of the Basic Antenatal Care principles of good care and guidelines in pregnant women’s antenatal care records. African journal of primary health care & family medicine, 8(2).

Rabelo‐Silva, E.R., Dantas Cavalcanti, A.C., Ramos Goulart Caldas, M.C., Lucena, A.D.F., Almeida, M.D.A., Linch, G.F.D.C., da Silva, M.B. and Müller‐Staub, M., 2017. Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA‐International (NANDA‐I) and Nursing Interventions Classification (NIC). Journal of clinical nursing, 26(3-4), pp.379-387.

Stevens, S. and Pickering, D., 2010. Keeping good nursing records: a guide. Community eye health, 23(74), p.44.