Nursing Documentation and Legal Compliance

A good record keeping in nursing can be established if the nurses properly mention the care information supported by proof in the report which is duly signed and properly timed in such a way that it when referred, can trace the person whose care has been documented (Mutshatshi et al. 2018). In this assignment, the record-keeping in the area of nursing is to be explored. This is because it is seen that nurses are responsible to keep proper records of the patient’s treatment which they later use as reference to determine the way care support to specific patients are to be provided in better way (Mathioudakis et al. 2016). In this assignment, an overview of record-keeping in nursing is to be discussed and the laws which are to be abided to protect the patient information in the records. The experiences regarding record keeping in nursing are to be discussed and the way it relates to the NHS values are to be explained. The record-keeping in nursing is referred to keeping proof of the care provided by the nurses for later reference in developing care practices, use as evidence in criminal prosecution and legal claims in nursing care helping to protect patients and the nurses along with allow care quality for patients to be improved and managed (Charalambous & Goldberg, 2016). The Nursing and Midwifery Council (NMC) informs that for effective record keeping in nursing the nurses are to complete the records of care immediately after the care event. Moreover, in the record, the nurses are to mention the problem raised and the steps taken to manage them in the care to help the colleagues who use the record later have required information. The NMC Code also mentions that records are to be completed with authenticity and appropriate steps are to be taken to ensure the records are kept in secured manner (NMC, 2018). For example, nurses should record patient's information, such as date of birth, address, medical history, allergies to medications or infection risk, and the contact details of the next of kin (Dougherty & Lister, 2015). The patient's pain type and location, respiratory level, nutrition intakes, temperature, and sleeping pattern, and their religious beliefs (Dougherty & Lister, 2015) must also be logged. In order to keep correct records, nurses must note the actual time, date, and give their signature (Dimond, 2005).

The record-keeping is important in nursing as it offers updated and accurate information regarding patient at any point of care allowing the nurses to make fewer errors in care, achieve a better diagnosis of the patient, offer safer and quality care (Lindh et al. 2018). Thus, recording keeping is essential as it leads to improve the productivity of the nurses and show greater efficiency in delivering care. The patient records when are kept in a way that is below the standards mentioned by the NMC and NHS it leads to create error in care delivery by the nurses. This is because the falsified or incomplete care records of the patients when are used as reference by the nurses it makes them remain confused and unable to be assured regarding the exact ways care for the similar patient is to be delivered (Bijani et al. 2016). Thus, such condition leads the nurses make error in care leading the patients to avail hindered support for their health condition. Moreover, when the record-keeping in nursing care is below standards it creates confidentiality issue for the patients because the effective protection to keep the personal data of the patients in a safe and secured way is not maintained (Akhu‐Zaheya, Al‐Maaitah & Bany Hani, 2018). In addition, below standards record keeping in nursing makes nurses remain unclear regarding the way similar risk raised in care delivery for other patients are to be resolved to lead to create quality issues in care support (Bijani et al. 2016).

The accountability in nursing is referred to taking responsibility by the nurses regarding the judgement made, care action performed and omissions made in support services for the patients while providing them care. The accountability in nursing is important as it is related to life-long learning, upholding care quality and outcomes for the patient, maintaining competency and ensuring professional standards are abided while offering care to the patients by the nurses (Sand-Jecklin & Sherman, 2013). The accountability relates to the record-keeping as the nurses are regarded to be responsible for making accurate and timely recording of care in the form of notes after the care event. Thus, in case any falsified information are recorded or any incomplete information is present in the record the nurse in-charge are held accountable for the error and low-quality standards of the report (Charalambous & Goldberg, 2016). Therefore, nurses are to ensure they make proper notes of care in timely manner to effectively perform their duties.

Looking at the legalities, patients' confidentiality is protected by the Data Protection Act 1998, and it prevents risk and harm for the service user (2013). Under this law, the patient's personal (Dignity in care - Key legislation: Information legislation, n.d) family life are also protected. For example, health professionals cannot share any information about the patient, client, or even colleagues without their permission. Another legal aspect is that student nurses can keep medical records, but ought to do it under a mentor or supervisor. Furthermore, they will need a countersign as evidence, and countersignatures will be required until student nurses are confident to complete the activity on their own (RCN, Delegating Record-Keeping and Countersigning, p5). The Data Protection Act of 1998 states that people who use care services have the freedom of information (legislation.gov.uk, 1998). Therefore, patients and clients are eligible to see or request their medical reports to check what nurses have recorded about them. The Data Protection Act 1998 informs that no information of the individuals is to be shared without their prior approval (legislation.gov.uk, 1998). Thus, nurses, before using the records of the patients and sharing the information with others, are to take prior approval of the patient. Accordingly, nursing guidance is set for delivering effective care: nurses must be careful not to be rude, use ill-mannered words and unrecognized abbreviations. They must not give personal opinions, write anything judgemental, breach patient confidentiality, keep a false record, or any other discriminatory or bullying interpretation in the patient's record ( Recordkeepingg, 2016 first -step). If they do so, they could be faced with misbehaviour issues such as imprisonment and have their name removed from registration according to NMC Code (NMC FTP library). On the other hand, nurses also should not eliminate what they or someone else has written on the record (Dimond, 2005). Nevertheless, identification of nurses in the report such as hospital registration number, job role, name, and signature can be used to identify the professional who kept that record for any legal misconduct issues (RCNi, the principle of record-keeping 2016, p35).

Health professionals can record the patient's information in three ways: Verbal, Nonverbal, and Electronic. The electronic patient records are seen to be kept by the general practitioners (GP) to be later use as reference of care for patients with similar health condition. For example, a GP keeps a computer base record of saved medical history and ongoing medication information of the patient. No-one has access other than healthcare professionals for the system as it is security password protected (ausmed.co.uk, 2018). Also, it is the quickest way for health care professionals to share patient's information with the relevant healthcare departments. A non-verbal record can be interpreted as medication, vital signs observation, and pain score charts, plus blood test results. When healthcare professionals receive and analyse these charts, it gives information about of the situation or the health problem the patient is going through, and GP can make an action plan for the patient to improve their overall health (bhf.org.uk, 2018). Nurses can do verbal record-keeping such as bedside handover when observing the patient's facial expressions and professional communication with colleagues and can pass on the patient's current situation.

The presence of effective communication is required to support and build a therapeutic relationship so that individual patients can feel heard and understood. The record-keeping helps to improve therapeutic relation by mentioning the nurses the way communication is to be established and aspects to be considered for patient who is suffering from similar health condition as mentioned in the reports nurses are using as reference to provide care (Akhu‐Zaheya, Al‐Maaitah & Bany Hani, 2018). A healthy therapeutic relationship must be built between the nurse and the patient as it would lead to develop trust among the patients making them confide in the care provided by nurses. This is required as the trust helps the patient open-up and release their health worries and wishes to the nurse whom they trust (goodtherapy.org, 2019). This also suggests communication is an essential part of the nursing career, as effective communication builds trust, makes patients feel less worried, and accelerates the patient's healing process. For example, in the ward, a patient was admitted from suffering from sight loss and vocal problems. It is a significant issue when caring for like this patient as the patient relies on the nurse's guidance as they cannot speak clearly and cannot see properly. In this case, the nurses or the student nurse would refer to previous health reports of similar patients to determine the way to communicate clearly with the patient as they do not know what is going on in their surroundings. This would lead nurses make gradually understand and believe them leading to build a therapeutic relationship. To conclude record keeping is a vital component to the healthcare sector. Without it, many problems will occur, and patients will not receive the correct treatment. Many elements fall under contemporary nursing, however, the predominant one is giving holistic care to the patient, for them to trust and feel safe.