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Record Keeping in the Medical Profession

With all quite demands in any nurses' working day, as a nurse the individual may believe that keeping nursing files is a distraction from the real work that the customers of the multidisciplinary team have to do: looking after patients. Unfortunately this is not the truth; record keeping is really one of the most important areas of the nursing career.

Without clear and accurate nursing records for every single individual patient it is impossible for any person in the multidisciplinary team to remember everything that has been done and everything that has happened over a shift therefore influencing the wellbeing and protection of an individual. This aspect of patient safeness and record keeping is not only good for the nursing staff but also to the patient. The issues of record keeping and patient safeness will be talked about throughout this essay with the use of articles from publications and NMC recommendations.

The Nursing and Midwifery council believes the record keeping is an integral and important area of the nursing career. (NMC, 2010) Record keeping is a multidisciplinary procedure and a specialist tool which really helps to assist in the caring process. Diamonds States that all details must be placed but principle as part of the duty of good care owed to the patient not for the protection of members of the multidisciplinary team. (Stone, B, 2005)

A nures record keeping skills mirror on how they are really as practitioners. In case a nurses details are untidy, vague and simply generally not good this suggest that the nurse in question is much less intersted in the individual or their basic safety as they should be, on the otherhand a nurse who is patient centred and cares because of their patients by ensuring that their nursing records are written following the NMC guidlines.

The NMC suggestions declare that all files must be recorded timeously and consecutively and must be plainly written and long lasting. They need to also be factual, steady and clear including no jargon, abbreviation or meaningless phrases. Every entry into the patients notes irrespective of which member of the multidisciplinary team has written it must all be dated, timed and signed with printed name and designation. If the individual has made one they should never use correction fluid it ought to be singly scored, dated, timed and singed.

It is important that the details are written with the individual or carer and recognizes the difficulties that the individual is having and the activities that are being taken to help the patient to beat these problems. The information must show proof the care which is organized for the patient, decisions which were made, the care that the patient has received and the info distributed and who it was distributed to.

Good record keeping promotes a higher standard for good care as it shows that the nurse is a safe and skilled practitioner with good communication who consists of the individual in the conversations with other medical specialists. Good record keeping also has an accurate profile of good care planning and delivery of good care for every single patient and could also provided a means of detecting an alteration in the patient's condition early on. Record keeping is a multidisciplinary way of working and is also attentive to the patients needs.

There are various types of information which nursing personnel could keep regarding patient information and the attention they have or are getting. These include treatment plans, the must verification tool and the early warning score graph.

The creation of a care plan can be an intermediate stage of the medical process. A attention plan is a set of actions a care staff member will put in spot to support the medical diagnosis that the nurse has given the individual. These diagnoses are determined by the initial medical assessment. This helps to steer the ongoing health care that the patient has received and aids in the evaluation of the attention.

A health care plan is also an arrangement between a patient and the multidisciplinary team they are closely working with to screen their daily health. The care plan may include goals that the average person would like to achieve, medicines, emergency contact details, eating and exercise ideas and what services they might need. When writing the attention plan people of the multidisciplinary team have to take into consideration things such as the must verification tool.

The malnutrition widespread screening tool (MUST) is a five step testing tool used to identify people who may be vulnerable to malnutrition or obese. It is the first step to identify those who may be a threat of malnutrition and who then may necessitate some kind of intervention. It is a trusted tool by all people of an multidisciplinary team on first connection with a patient to enable them to select appropriate healthy advice permitting them to develop an sufficient good care plan.

The five steps include weighing and measuring an individual's level to get their body mass index, noting the individuals unplanned weight damage and report using the correct tables, establish the effect the individuals health conditions have on their weight and rating, add all results from steps one, two and three alongside one another to get the individuals overall credit score then use local insurance plan or management guidelines to develop the individuals caution plan.

Finally customers of the multidisciplinary team have to complete early warning score charts that are also part of the record keeping process. The first warning score graph is a way utilized by medical staff to be able to quickly determine whether a patient are at risk of loss of life by observing five physiological readings, included in these are the patients' blood circulation pressure, respiratory rate, heartrate, body temperature and oxygen levels in the blood vessels. They also observe the patients level of consciousness, nausea and exactly how much pain they may be in. Once many of these have been observed the chart is filled in and the patient is given a rating for each between zero and three, if the individual has received a three for any of them then your appropriate implications can be put set up, if the score the average person receives is above five then there can be an increased probability of death.

Every patient's information is guarded by the info protection. The Data Protection Action 1998 defines a health record as "consisting of information about the physical or mental health or condition of an identifiable specific made by or on behalf of a health professional regarding the the care of this individual". This applies to all types of information whether it's a handwritten take note of or a photograph.

The data safeguard act protects the rights of the individual in relation to data which is obtained, stored and refined or supplied regarding them. (NMC, 2010) The work requires that appropriate options will be taken against unauthorised access to, or modifications, or destruction of personal data. Breaches are determined by the information commissioner.

It is also important that records are stored confidential. All NHS staff have a work to keep all documents and information within those information about a person private and stored away firmly. (NMC. 2009) The only way personal health information may be shared with other is if the individual needs to know relevant information about the patients health such as a social worker, health care or home help. The information may only be distributed if it's needed to give the patient appropriate treatment and treatments or if the patient has given consent.

Usually Personnel of the NHS will not share any information with relatives or carers without out the patients' permission but there are many exceptions that can be made. These include if the patient is under 16. If this is the case the information in the documents can only just be distributed if doctor doesn't feel that the average person can make a medical decision then someone with parental responsibility may be allowed to go through the childs health files and make a decision with the person.

If the patient has ended 16 information maintained in the patients records can only just be shared if the individual cannot make decision for themselves or cannot notify others their decisions, regulations allows another person to have access to their files and discuss their good care if the individual has given them a welfare vitality of legal professional or a judge has given them a welfare guardianship or a welfare intervention order. If this is actually the case then your individual is only going to have the ability to see information that is essential to allow them to make particular decisions for the average person about their health and will not get information that personnel feel would be bad for the health of the individual or others.

Confidentiality benefits patients' security by giving a secure environment where they are likely to seek medical care and to provide a detailed account of the illness. In addition, it expresses admiration for patients' right: They may have a right to choose who will have access to information about them, and a rule of confidentiality for doctors reassures patients that they can determine who will be access their personal information.

The main reason for built-in record keeping is to have an accurate bank account of the good care and treatments that the individual has previously had or is currently having. This enables the individualsp progress to be monitored and a scientific history to be developed. Having this specialized medical history will allow members of the multidisciplinary team to protect the individual as it offers information about the individuals' previous health issues, allergies and prior medications. This allows the multidisciplinary team to organise a plan of action for the average person and prevents the individual for receiving needless treatment or arriving to unnecessary damage. Having this scientific history to hand will allow the patient to help make the most of the time they have got with any person in the multidisciplinary team, permitting them to get the enough medical attention that they might need. It also allows a common showing of the components of clinical process like the planned structure of care, the way it is supplied and the ongoing evaluation of the individual thus making the patient feel supported. At exactly the same time, it will allow users of the multidisciplinary team to share their views on the individual and allow for data to be saved and presented based on the views of customers of the team. In addition, it should include ways that to monitor the grade of care.

Record keeping is an excellent tool for users of the multidisciplinary team to converse effectively. (Hutchisons, C: Sharples, C. 2006) Having the ability to communicate through this multimedia allows them to share important information about a patient's medical history or needs and never have to talk about them. This may prevent the patient from arriving to inadvertent damage.

Communication can be an essential requirement of good record keeping and patient safety as it is essential that the average person understands anything that is going on or is going to eventually them regarding their attention and health. In addition, it enables users of the medical team whether it is physiotherapists, nurses or doctors to know about their patients' health. This is done through record keeping.

Another important concern is the legal significance of nursing documents. If a person makes an official grievance about the attention they received then your nursing documents that are stored will be the only proof that the participants of the multidisciplinary team have satisfied their responsibility of good care to the individual. The information will show a full accounts of the patients' evaluation, planning, the implications of these good care and the evaluation of their care. It also enables legal professionals to see all the procedures taken to react to the patients evaluated needs. The information will show that the multidisciplinary team has understood their obligation of care and everything the sensible steps that the users of the multidisciplinary team have been taken up to maintain the patients safety. In addition they include the arrangements for continuing care and attention and the entries occurrence are written to commensurate with the patients conditions.

In final result record keeping is effective to keeping patient protection as it allows members of the multidisciplinary team have clinical history that helps prevent the patients from approaching to any needless harm. In addition, it promotes good communication in just a multidisciplinary team that will effectively plan the near future treatment or current care and attention of a person. It offers all the important info that might help determine what the individual may have required medical assistance for, for example transferred medical ailments or allergies that the individuals may have. This allows customers of the medical personnel notice any underlying health issues and resulting in the staff having the ability to address it effectively, resulting in maintaining patient protection. Having good record keeping skills prevents from mistakes and blunders from being made or heading unnoticed therefore mainaing the protection of the patient all the time. This shows that record keeping skills are crucial in the nursing profession not merely for the nursing staffs safety but that of the patients too.

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