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Disadvantages of keeping records
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Identify a core principle from the NMC Code of Conduct (2008) and demonstrate how this may affect professional practice This essay contains discussion on the importance of proper documentation and record keeping as a core principle of the NMC Code of Conduct. The report further highlight how this may affect professional practice and the implication of poor record keeping practice. Medical records are the most basic of clinical tools (Pullen and Loudon 2006) and their main importance is to serve as a form of memoir or aid in client and patient support. Medical records therefore provides essential evidence of care provision, thereby enabling effective communication between health care professionals, members of the multidisciplinary team and all clinicians as a whole. One of the main expectation from all Nurses and Midwives as laid down in the NMC Code of Conduct (2008) is that all Nurses and Midwives must keep clear and accurate records. The Department of Health’s (DH) policy statement on record keeping also place a responsibility on all health professionals to ensure that all records created and maintained are accurate, current, comprehensive, concise and legible. Such records should also provide information concerning the condition, treatment and care of the patient and associated observations (DH 2002). However, for any medical record to serve the purpose for which it is meant for, it has to be “contemporaneous, unambiguous, legible and accurate” (Dimond, 2005). Accuracy of records could be described as the most important factor when it comes to record keeping practice in nursing. This is because accuracy in nursing records and documentation provides a real timeline information of the various stages of care provision. Prid... ... middle of paper ... ...t Dimond, B (2005) Exploring the principles of good record keeping in nursing: British Journal of Nursing, 14(8) Dimond, B (2005) Prescription and medication records: British Journal of Nursing, 14(22) Ian, D. and Loudon, J (2006) Improving standards in clinical record-keeping: Advances in Psychiatric Treatment, 12, pp. 280 – 286 National Health Service Litigation Authority 2011: Report and Accounts London, NHSLA Available from: www.nhsla/NR/rdonlyres/annualreportandaccounts2011.pdf Accessed October, 2013) Nursing and Midwifery Council (2008) Standards of conduct, performance and ethics for nurses and midwives Pirie, S (2011) Documentation and record keeping: Open learning zone, 21(1), January Prideaux, A (2011) Issues in nursing documentation and record –keeping practice: British Journal of Nursing 20(22) Wood, S (2010) Effective record- keeping: Practice Nurse, 39
The SSSC codes of conduct contains 10 codes 5 are for employees and other 5 are for employers where as in the NMC there is 4 codes which are, prioritise people, practise effectively, preserve safety and promote professionalism. Both codes are very similar even when dealing with different patient groups both codes state in 1.1 to prioritise people and treat each person as an equal individual. These both codes of conduct should be followed correctly at all times by anyone working in the health and social care. The NMCs aim is there to protect the public and decides if a nurse or midwife is fit to practice up to their high standards. The NMC was published on the 29th January 2015 but didn’t come effective to 31st March 2015.
The adoption of clinical information systems is one way that healthcare organizations are making an effort to improve patient safety, provide a means to exemplify regulatory compliance, and facilitate exchange of patient information between care providers (Kirkley & Stein, 2004; Nadzam, 2009). To achieve this goal, Barnes-Jewish Hospital (BJH) recently implemented a new CPOE/clinical documentation system. One of the objectives of the new system was to give bedside clinicians a standardized electronic tool, known as the Clinical Summary, for bedside shift hand-off reporting. Soon after go-live, it was identified that the standard nursing Clinical Summary did not meet specialized the reporting needs of the nurses on the Women and Infants divisions. Consequently, an application enhancement request was submitted. The goal of this project is to synthesize the knowledge gained throughout this Masters Degree program to initiate, plan, and execute changes to the current clinical documentation system to provide a standardized Clinical Summary review screen to meet the specialized hand-off reporting needs of the nurses on the Women and Infants divisions at BJH. This paper includes project objectives, a supporting evidence-based literature review, project methodology, formative and summative evaluation criteria, and a graphical timeline with a narrative description for the Women and Infants Clinical Summary project.
NAEYC. (2005, April). Code of Ethical Conduct and Statement of Commitment. Retrieved May 13, 2010, from NAEYC.org: http://www.naeyc.org/files/naeyc/file/positions/PSETH05.pdf
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Which is very important for nurses or any medical professional to do in the healthcare profession. Nurses are receiving these patients in their most vulnerable state, nurses are exposed and trusted with the patients’ information to further assist them on providing optimum treatment. Keeping patient’s information private goes back to not just doing what’s morally right but also it also builds that nurse – patient relationship as well. We also have provision three that specifically taps on this issue as well, as it states: “The nurse seeks to protect the health, safety, and rights of patient.” (Nurses Code of Ethics,
...Council, M., & Federation, A. N. (2008). Codes of Professional Conduct & Ethics for Nurses & Midwives, 2008: Australian Nursing and Midwifery Council.
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
1. Legal, ethical and professional principle frameworks underpin all fields of nursing, and it is a requirement for all Registered Nurses to be competent and knowledgeable, act with integrity and maintain professional standards set out by Nursing and Midwifery Council (NMC, 2015). Working with multidisciplinary teams within our profession, it is important to acknowledge and recognise the way in which all the professionals are guided by law and their independent regulatory bodies. The needs of the individual patient is to be considered by doctors and nurses alike, who share professional values and are set out in the respective codes of practice, The Code (NMC, 2015) and GMC (2013).
Nursing and midwifery council (2008) The Code: standard of conduct, performance and ethics for nurses and midwives. London: Nursing and Midwifery council
The Codes of Practice is issues to all registered nurses, midwives and health visitors. The Council i...
Continued Professional Development is now an important part of ongoing registration with the NMC and is essential in maintaining professional standards. In order to revalidate, nurses must write 5 reflective accounts within a 3 year period and each reflective account must explain what the nurse has learnt from the CPD activity and explain how it relates to the Code of Conduct and in particular the 4 themes of Prioritising People, Practicing Effectively, Preserving Safety and Promoting Professionalism and Trust.. Nurses also have to discuss the written reflective accounts with another NMC registered nurse coving the 5 reflective accounts Section 9.2 of the NMC code of conduct asks nurses to “gather and reflect on feedback from a variety of sources, using it to improve your practice and performance” (NMC, 2015) This is why the NMC promotes reflective practice as it ensures the nurse is practicing within their competency and in a safe manner while identifying any areas for improvement in their practice Reflective practice also makes the nurses more accountable for their actions.. (NMC, 2015) Reflective writing is an important feature of professional practice. Nurses have to keep a record of their continued professional development. At annual reviews nurses are able to present evidence of their development through a portfolio which should contain reflective accounts of their practice. These reflective accounts will help them identify strengths and weaknesses, highlight their performance, improve their skills and highlight any area that could be
NSNA (2003). Code of ethics for nursing students Part I: Code of professional conduct. Retrieved June26, 2011, from: http//www.nsnsa.orgpdf/pubs_CodeofProfessionalConduct.pdf
Dougherty, L. & Lister, s. (2006) ‘The Royal Marsden Hospital manual of Clinical Nursing Procedures: Communication 6th Edition Oxford: Blackwell Publishing Ltd
Nursing Council of New Zealand. (2009). Code of conduct for nurses. Retrieved March 15, 2011, from http://www.nursingcouncil.org.nz/download/48/code-of-conduct-nov09.pdf
Charting plays an important role in the nursing program by enabling safe and effective patient care (Lewis 15). Likewise it can also be closely associated and differentiated to memoirs in terms of communication and privacy.