Improving Nursing Communication

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

“We learned in nursing school that a patient record is a legal document. We also learned that ’if it isn’t charted, it isn’t done.’ We should consider these facts in practical terms and not just as something our instructors repeated numerous times”(Anderson,, 2012, para. 2 ).I completed my nursing diploma in 2011 and worked for a while before entering into Post-basic BSc nursing course in India. While getting orientation, the hospital administration taught the workers the importance of documentation and the methods used in our hospital setting. This institution used to keep every minute detail regarding patients for the well- being of them as well as for the employee. Once a patient got hospitalized, it is the responsibility of the nurse to record each and every event associated with that person. These recordings included care given, medications administered, laboratory

Issues and dilemmas highlighted by this incident Management issues Several management issues where highlighted by the incident. The analysis will focus on record keeping, effective communication, risk management and ethical issues. The day to day management issues affecting nursing practice such as record keeping, effective communication and risk management do not operate in isolation but are frequently interdependent and affect each other. The central focus will be on the observed failure by the night duty nurse to record or pass on information on Mark’s report. The Nottinghamshire Healthcare NHS Trust (2009) policy on record keeping states that a record of an event must be made immediately or within 24 hours of the occurrence. The rationale for this requirement is that an immediate record of

Confidentiality is critical for nursing professional to understand and undertake. If a nurse did not keep a

Health information is an important source of information and evidence when the services provided are communicated in legal and professional documentation. It is a documentation which is a legal requirement and a record of the beneficiary’ care as well as a communication vehicle between other disciplines and providers. It not only ensures the services provided to individuals but is a crucial tool to support reimbursement of services and a basis for research. Incomplete and improper documentation potentially may lead into a denial of payment for services as well as question’s the quality of care provided.

Poor communication puts patients in danger because it can lead to medical errors and adverse events. For example, a medication error can occur if a physician’s orders are not updated in time or if the outgoing nurse does not provide the correct time in which a dose was administered last. Thus it is crucial to communicate any recent treatment that has been implemented. In this way, nurses and physicians can facilitate the prevention of errors. Another consequence of ineffective communication is that it can decrease morale and increase work-related stress among members of the healthcare team. If nurses and physicians are not understanding each other’s actions, conflict ensues. It can cause toxic interpersonal relationships. This, in turn, will affect the level of patient care because it is difficult to focus amidst emotional strain and

Listening can help with connecting with other people, to feel cared about, accepted, and feel significant and respected as well as feeling heard and understood (Department of Health, 2002). Any form of communication should be recorded according to Data protection Act (1998), good record keeping apply to all types of recording for example clinical notes, emails and letters.

This essay will highlight one of the key concepts of nursing .The concept that will be discussed in this essay will be communication, the reason for this chosen concept is that communication plays a vital role in everyday occurrences which defines how a situation is perceived by yourself, others and how communication is effectively handled . There will be a definition on what communication is also an evaluation of the chosen concept will be explored throughout this essay.

The most relevant theory in this situation is the preservation of integrity for the patient and in my practice. In order to preserve integrity and social justice I want to attain a respectful nurse-patient relationship. The nurse-patient relationship in high acuity as written in Module 1 BCIT High Acuity course “is one of the central aspects of high acuity nursing practice” (Bungay, 2005, p. 40). I feel confident this theory is the central aspect of all nursing practice. All patients, including the one I’m referring to in this journal, has her own unique beliefs, history, and experience. On top of these, the patient is now, due to critical illness, experiencing an actual or potential physiological crisis (Bungay, 2005, p. 42). It would useful and respectful of me to acknowledge that on top of her present concerns, all concerns she had prior admission still exist. I did not give her the opportunity to express her concerns. I never asked her if she had a cat she was concerned about, was missing Saturday’s farmer’s market, wanted a Sherry, missed her friend, or disliked men. There could be a myriad of things that may be concerning her at the time. All real and potential factors support or challenge having a positive relationship with the patient (Bungay, 2005, p. 41).

This assignment will critique the enhanced communication skills between a registered nurse and service user. For the purpose of this assignment the service user will be referred to as Iris. Confidentiality will be maintained throughout, as stated by the nursing and midwifery council (Nursing and Midwifery Council [NMC], 2015). The physiological assessment being observed was blood pressure and will critique the communication skills, active listening, non-verbal, verbal communication and dignity. Verbal, non-verbal, visual and written communication are the four main types of communication (Boyd & Dare, 2014). During this observation Iris was having her blood pressure taken prior to commencing haemodialysis. Rapid removal of fluid increases the chance of hypotension during and towards the end of dialysis (Cormier, Magat, Hager & Lee, 2012). This is why it is important to monitor Blood pressure before, during and after haemodialysis. I observed Iris’s Blood Pressure being monitored prior to commencing haemodialysis.

Written communication in healthcare system comprises of care plans, daily reports, handover sheets ,medication sheets in general ,(record keeping). These clinical records are essential skills of communication that a nurse should be able to write as well as extracting vital information from which to provide relevant and precise care. This makes continuity of necessary care possible and fulfils one of NMC’s (2008) core principles of the code of working with others to protect and promote the health and wellbeing of those in nurse’s care and obligation to ensure total and effective information is communicated to your colleagues concerning people in your care (NMC 2010). These records help to increase answerability to the part of the nurse if the nurse is aware of this will be more considerate knowing that any mistake will come around. In addition these records help as the basis for decision –making for nurses and multi-disciplinary team of which the nurse

Mr. Comer was admitted to his local community hospital for respite care. He has suffered multiple, acute strokes in the past, which has left him with severe disabilities. These include paralysis rendering him immobile, aphasia (speech loss) and dysphagia (swallowing difficulties). He relies on carers for all normal activities required for daily living (Roper et al 1996) and is advised to have a pureed diet and thickened fluids.

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

Oral communication in healthcare is a continuous process and is extremely important for all those involved. Nurses relay relevant information to patients and their family, they are also responsible for updating the physician about the condition of their patients as well as nurse to nurse reporting. This communication is a fundamental part of the nursing process and can result in either quality effective care or ineffective care caused by lack of information. Written communication between the doctors, nurses, patients, and patient families can occur in a number of forms whether handwritten nursing notes or electronic medical records. Both forms are permanent