Importance Of Record Keeping In Nursing Practice

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ROLE OF RECORD KEEPING IN NURSING PRACTICE Introduction Clinical record keeping is an essential fragment of high class treatment and care and all nursing professionals have an obligation to record precise information about the care they are giving. According to Beach and Oates (2014) the relationship between the nurse and patient is changing rapidly and this will result in the way nursing staff record everything. The main reasons for keeping the records are to create a complete record of the patient in the services and to enable the continuity of care for that patient. The purpose of this essay is to explain the importance of good record keeping in nursing practice. Main Body Definition and Importance…show more content…
Edwards (2009) argues that the patient will lose the confidence in health system, if their confidentiality is not respected. During an examination, the patient is providing their all personal details to the nurse in charge and it is the nurse’s responsibility to respect it. Confidentiality should be maintained for all data unless the patient safety has been compromised or a crime committed. The Code of Professional Conduct and Ethics for Registered Nurses and Midwives (2014) states that the nurse’s role in confidentiality range from using social media to all kinds of information technologies. Most of the health care settings are changing from hand written records to electronic reports and the nurses should know the basics before going online. All the records should keep in a single place and if they have any concern regarding the safety, the nurse should contact the local personnel

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