The Health Records Of Nurses And Other Health Workers Essay

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

Confidentiality is a concept of vast importance for professionals in the medical field. It is a professional obligation in this field and is considered to be an ethical concept that falls in line with integrity, compassion, veracity, charity, and fidelity as explained in both the International Council of Nurses Code for Nurses (1973) and the American Nurses Association Code of Ethics (1985). However, in today’s ever growing world of technology and demand for information, challenges continue to arise that force doctors and nurses to reexamine virtues such as confidentiality.

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

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

Bedside reporting has the primary function of sharing patient information between nurses, as they change shifts. The nurse ending their shift would report all the changes that have occurred in the state of the patient and all measures which have been taken for the respective patient. This information would be transmitted to the nurse commencing her shift, who would then write and further transmit all patient information occurring during their shift, to the nurse coming to replace them.

I intend to look at why confidentiality is so important within healthcare and how it relates to the Nursing and Midwifery Council’s (NMC) Code. I will look at the

Traditionally, nursing shift-to-shift reports were organized methods of communication between only the oncoming and leaving nurse, designated to a location such as the central nursing station or nook of a hallway. Shift reports can be considered the foundation of how the day is going to plan out because it introduces the patient, diagnoses, complications, medications, consults, upcoming test and the entire plan of care. These reports are full of complicated and vital information and while set in certain locations that are vulnerable to interruptions, such as the nursing station, medical errors and miscommunication are more likely to be made. The Joint Commission’s 2009 and 2010 National Patient Safety Goals (Joint Commission, 2015) included two patient safety standards, first to encourage patients to be involved in their health care plan and second, to implement a standardized communication process for handoff reports between providers. Soon after in 2013, The Agency for Healthcare Research and Quality under the United States Department of Health and Human Services introduced a set of strategies to improve patient engagement along with safety and quality in patient care. Within these strategies the new method of nurse bedside shift report was developed, which suggests nurses to conduct shift-to-shift reports at bedside in the room of each patient, rather than out of the room. The benefits of this new method were

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

Bedside reporting involves giving information or a report to the oncoming nurse in the presence of a patient. This method gives the patient an opportunity to ask questions and get clarification regarding his or her care. Bedside reporting increases patient satisfaction, quality of healthcare and nurse-to-nurse responsibility. Hospitals need to design a better handoff process that can easily reduce patient risks and increase patients’ involvement in their care. Emergency rooms shift reports usually take place at the nursing station of every patient care area. The departing nurse gives information verbally to the oncoming shift. Therefore,

The NMC Code (2008) charges nurses to protect confidential information, and to only use it for the purposes given – for their treatment. Therefore all patients and events mentioned in this essay are inspired by real patients and events, but names, locations, dates and other details have been altered or obscured to make identification impossible. Following the introduction of the knowledge and skills framework (DH 2004a) and emphasis on quality of health care and patient centred, interprofessional, health and social care (DH 2000; Leathard 2003; Thompson et al. 2002) health care professionals and students will need to be able to

As healthcare providers, maintaining a patient’s confidentiality, human dignity and privacy is expected at all times. Nurses are faced with maintaining patient confidentiality on a daily basis. The Coded of Ethics for Nurses is the framework of nonnegotiable ethical standards and obligations that all nurses are to uphold. Nurses are to be accountable for their actions and are expected to advocate and strive to protect the rights, health and safety of patients (American Nurses Association, 2011).

Privacy is one of the fundamental policies and principles that should be adhered to by each professional nurse (Cileska, 2001). In addition, confidentiality is another equally important principle that should be observed by each of the nurses in the nursing profession. The reason for emphasising on confidentiality and privacy is meant to preserve the nursing ethics and to protect the privacy of the patients (Dickenson, 2004). Since most of the diseases are not meant to be exposed to the public, it should be the responsibility of each nurse to ensure that all patient information remains private and confidential this gives hope and trust to the

This essay will discuss why confidentiality is important within nursing practice and the reasons why a registered nurse and student nurse are accountable and to whom they are accountable to in relation to patient care. It will further discuss patient’s rights in relation to law.

At a practice level, the importance and guidance of the Code of Conduct, Code of Ethics and NPA are demonstrated on a daily basis with regard to the issues of documentation, informed consent and open disclosure, and confidentiality. With respect to documentation, nurses must be able to document patient assessments and responses in an accurate, comprehensive and confidential manner and record all observations objectively. Informed consent and open disclosure are also major legal issues nurses face daily. It refers to the communication between the patient and health professional that results in the patient's agreement to undergo a specific procedure and requires that the patient has thoroughly understood the procedure, implications and risks prior to giving written consent.