Assessing And Planning Patient Centred Care

Introduction

In nursing, record keeping of patient’s care and others helps in creating proof of care provided (Thupayagale‐Tshweneagae et al., 2020). In this assignment, principles of record keeping, and the legal issues related to contemporary nursing is to be discussed. Thereafter, the different ways of record keeping is to be explained and the impact of record keeping on the therapeutic relationship is to be discussed.

Principles and legal issues for record keeping in contemporary nursing

The section 10 of NMC Code of Practice mentions that records of the patients are to be completed immediately after any care event and in case of delay the notes are to be recorded to be written later (NMC, 2018). This is because avoiding delay in recording of patient data and care helps in avoiding loss of vital and minute aspects of information regarding the care (Hales et al., 2019). The NMC Code of Practice also mentions that any risk or problem which has been raised during the care is to be identified and steps taken to manage the problem is to be informed among thee nurses so that the record contains all the information required for effective record development (NMC, 2018). The principle helps in avoiding creation of misleading records or avoid addition of error in record due to lack of adequate availability of information (Kyte et al., 2020). The NMC Code of Practice also mentions that complete records are to be made with accuracy and without any falsified data. In case any error in record keeping in executed, one being aware regarding the condition immediate actions are to be taken by the nurses to resolve the error or falsified data (NMC, 2018). Thus, the nurses have key responsibility in creating relevant patients records to be kept for medical analysis and proof.

According to NMC Code of Practice, any entries made for recording in the electronic or paper model are to be effectively attributed to the person responsible and it is to ensure that facts for the records are written in clarified manner with time and data. The inclusion of abbreviation and unnecessary jargon is to be avoided within records (NMC, 2018). This is important to make the record kept to be easily understood when referred by other nurses or physician for medical purpose as well as have detailed account of the incidents mentioned in the records to plan actions. The NMC Code of Practice mention in respect to record keeping is that effective steps are to be taken to ensure the records are kept securely and collection along with storage and treatment of all data along with research finding are to be managed effectively (NMC, 2018). The Data Protection Act 1998 mentions that no information of the individuals is to be shared without their prior consent (legislation.gov.uk, 1998). This leads to create legal aspect for record keeping in medical and nursing care which is ensuring the records are kept in confidential and private manner so that they are not able to be accessed by the public (Shenoy and Appel, 2017). The violation of confidentiality of patients in record keeping would lead the legal issue to be raised for which legal action could be taken for the person responsible in managing the report.

In some cases, in nursing, the patient records are occasionally required as an evident before the law to investigate any complaint from the patient or local organisation. In this condition, the legal issue to be raised in release of personal records of the patients. However, the NMC Code of Practice mention that it is the duty of the nurses to ensure the patient's records are shared securely to the law without any opportunity of release of any data in the public (NMC, 2018). In some cases, the patient records are to be requested by professional governing bodies to examine and investigate the claims regarding any misconduct in care (Stablein et al., 2018). In this condition, effective care is to be taken to formally present the record of the patient in the event to support investigation (Abdekhoda et al., 2019). Therefore, record keeping of the patients in the contemporary nursing is to be made in comprehensive manner and no acts of omission of information are to be performed during record keeping.

Way of Record keeping

One of the initial ways of record keeping in nursing is verbal recording which is important during nursing handover (Sanjuan-Quiles et al., 2019). The example of verbal recording is available from my practice when at the time of nursing handover of a patient I needed to provide verbal account and record of the health detail and performance of the patient. In the verbal recording and relaying of data of the patient to the other nurse, my responsibility was to provide updated record of the vital health units of the patients, the medication which are provided and left to be administered, any new patient needs to be supported, extent of care completed for the patient and other.

The other way of record keeping in nursing is through written format in which the details of the patient care is recorded in a standardised form so that consistency and systematic approach is implemented in the process to ensure effective documenting (Blijleven et al., 2017). For example, in my practice placement, the written recording usually beings from the fulfilling of the identification sheet of the patients. It follows inclusion of continuation sheets in the written recording where patient vitals and medication administration along with additional support provided with gradual progress in care being reported and recorded. The written record includes date, time and signature of the nurse responsible in recording the data and include facts to be patient vital to be written with accuracy without use of jargons. This is because the written records of the patients maintained on timely and daily basis are analysed by the visiting physician to determine the progress in health of the patient.

Record keeping impact on development of therapeutic relationship

In nursing, record keeping of patient care has wide impact on various aspects of therapeutic support. As mentioned by Didry (2017), record keeping in nursing impact to create enhanced holistic care delivery to the patient. This is because the patient records are able to be reviewed by the members of the multi-disciplinary team who become equally aware of the current patient condition apart from nurses and physicians. It makes them understand the role to be played for the patient and additional care support with the use of their expertise are to be provided to the patient for their better-quality individual care (Didry, 2017). As argued by McCarthy et al. (2019), hindered health records of the patients confuses the multi-disciplinary team members regarding the health progress and efficiency of the patient. This is because hindered recording lack current health vitals and needs of the patients which makes the multi-disciplinary team member unable to understand in which aspect support are required by the patient to ensure them enhanced holistic care.

The record keeping of the patients impact to create enhanced family-centred care. This is because the records provide information about the current health scenario and seriousness of needs of the patient to their family members. It makes the family members aware of the importance of their participation in caring for the patient and in which way they are able to assist in care for improved patient health (Facchinetti et al., 2019). In addition, the record keeping of the patients also helps the nurses to understand the family context and scenario of the patients. It makes the nurses aware regarding which family members are to be approached and way the family members are to be included in deciding as well as delivering supportive care to the patient for their enhanced well-being (Didry, 2017).

The NHS value include working collaboratively for the patients and act in best interest for them (NHS, 2021). The record keeping of patient data impact effective fulfilment of the value by acting as point of reference for the nurses, physicians and multi-disciplinary team regarding the patient. They use the records to consult and communicate between one other the care role to be played by each one of them to deliver quality support for the health improvement of the patient. The NHS value include showing commitment to deliver quality care and improve lives of the patients (NHS, 2021). The record keeping of the patients helps in fulfilling the value because the records are analysed at each context of care by the nurses and physicians to monitor the progress of health of the patient. They also refer the records to determine in which aspect of care additional support are required for the patient so that their well-being and health can be improved.

The record keeping of the patient impact the professional behaviour of the nurses and physicians to be managed effectively. This is because hindered behaviour if recorded within the patient report would lead the professionals to face queries and legal action that may make them get evoked of their registration in worst cases (McCarthy et al., 2019). The record keeping acts as proof of the professional behaviour of the nurses and physicians. This impact them to use the records as evidence to save themselves from unnecessary dispute or be proven guilty in case of hindered showcasing of behaviour (McCarthy et al., 2019).

Conclusion

The above discussion mentions that according to NMC Code of Practice the records of the patients are to be maintain in confidential manner and recorded in such as way so that not falsified data are present. The different ways of record keeping include verbal recording, written and electronic recording that are used in different instance of care. The record keeping impact top enhance individual care, influence positive family-centred care, meet the NH values for care and ensure effective following of professional behaviour by the medical professional and nurses.

References

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Blijleven, V., Koelemeijer, K., Wetzels, M. and Jaspers, M., 2017. Workarounds emerging from electronic health record system usage: consequences for patient safety, effectiveness of care, and efficiency of care. JMIR human factors, 4(4), p.e7978.

Didry, P., 2017. The evolution of nursing record-keeping. Revue de l'infirmiere, 66(231), pp.20-21.

Facchinetti, G., Ianni, A., Piredda, M., Marchetti, A., D’Angelo, D., Dhurata, I., Matarese, M. and De Marinis, M.G., 2019. Discharge of older patients with chronic diseases: What nurses do and what they record. An observational study. Journal of clinical nursing, 28(9-10), pp.1719-1727.

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