Team Working

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Outcome 6. The importance of accurate record keeping.

Accurate record keeping is very important for few reasons. First of all, different health professions are involved in patient care delivery and clinical process. All these professional have to communicate about patients and records is one of the best ways of doing it. Secondly, records reflect all procedures and manipulations with a patient in a chronological way so that members of staff know exactly the situation with patients to provide 24 hours care for patients. . Thirdly, accurate record keeping is important for investigating complaints and claims. The best care provided will not be counted if it was not recorded in patient’s notes (McGeehan 2007).

Records should be written briefly but informative at the same time. It should be focused on the patient, factual, measurable and realistic. It also should be written strait away after an event. The nurse should put date, time of the note and write her name. Handwriting should be easy to understand. The language should be appropriate without abbreviations or jargon. Poor note taking can be regarded as negligence (McGeehan 2007).

As every patient has different reasons for admission and different pathway on a ward, it is important to work out care pathways. It includes clinical risk assessment and outlining the care that this patient should be given recording to conditions. All members of the staff must sign when they use a pathway for a patient (McGeehan 2007). .

Trusts can be assessed by The Clinical Negligence Scheme for Trusts (CNST) by the way records were kept. As there are many complains and claims, every nurse should follow high standard record keeping so that records can be used as an evidence of care provided in a court (McGeehan 2007).

References:

McGeehah R (2007) Best practice in record keeping. Nursing Standard 21(17), 51-58

Outcome 7. Informed Consent.

The concept of informed...
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