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.
Virginia Henderson said in an interview “Nurses always think about how can they help this person to become independent of the nurse at the earliest possible time which can’t be standardized but individualized. The patient should never feel like they are forced to do something against their will or better judgement. One of the serious flaws in healthcare that the patient involvement is not optimized. When there is no hope of the patient living constructively or they don’t want to live any longer, when death is inevitable it is terribly important for the nurse to make sure that the patient has a good death.” She defined the patient as someone who needs nursing care, but did not limit nursing to illness care.
The nurses main aim is to give as much independence back to the patient at all times. The nurse never should do something for a patient that they can do themselves eg. feeding. The model, although not recommended, is used almost like a checklist on admission of a patient to gauge their dependence on the nurse. Roper herself said that this model is simply a tool and should not be used solely alone, however, oftentimes in the UK it is (nursingtheory.org, 2013).
One of the most important attributes of nurse-client relationship is trust, which is necessary to maintain the collaborative nature of the relationship. To develop trust, nurses must "be reliable, knowledgeable, with sufficient experience, and with a genuine desire to help patients" (Ozaras & Abaan, 2016). As a nurse, I need valuable information from patients to provide optimal care, and if there is no trust between both parties, patients will restraint from
Davis (2017) defines accountability as being “answerable to oneself and others for one 's own actions.” This means that when a nurse engages in an activity on the job, she/he will be responsible for the outcome and might suffer negative consequences if her/his actions are careless or reflect poor judgement. Accountability provides a motivation for all professionals to perform well. Most people who are passionate about their profession have an internal desire to perform well, but accountability to one’s colleagues and patients provides an important external motivator to perform well. Nursing is unique as a profession because a nurse is in a position of authority and care over patients.
Code of ethics is a primary goal in the nurses’ life that provides the value of the profession which points to the acceptance of the responsibilities and trust which nurses have developed with their patients and the society (Burkhardt, Nathaniel, & Walton, 2014, p. 195). “The code guides ethical relationships, responsibilities, behaviors, and decision-making, and used in conjunction with the professional standards, law and regulations that guide practice” (CNA, 2008, p. 2). Maintaining privacy and confidentiality is the primary ethical issue presented in the case scenario. As a nurse, it is essential to maintain the privacy and confidentiality of the patient by following ethical values, as the patient has the right to keep the situation confidential (CNO, 2009, p.7). Confidentiality is “keeping personal information private related to the physical, psychological, social health of clients, and any information collected during providing nursing services” (CNO, 2009, p.7).
PART A: DIGNIFIED CARE IN NURSING: Dignity; “the state or quality of being worthy of honour or respect.” (Oxforddictionaries.com, 2016). Nurses must respect patient dignity because they have a duty of care to each client. Without respecting this, a patient may feel they have not received the correct standard of care, which may prolong their recovery time.
In healthcare, nurse-patient communication involves giving out and obtaining information which allows the nurse to know the needs or problems and feelings of the patients. 3.1 Personal concept In order to achieve great outcome of individualized or holistic care of patients, effective communication between the nurses and patients is required. Communication is a vital tool in nursing care. The purpose of nurse-patient communication is to create a nurse-patient therapeutic relationship,
Our one commonality as nurses is our commitment to quality patient care. We know, both individually and collectively, that nurses are regarded as honest and valued by our patients. This is the way a person appears to others, or in the case of a profession, the way that profession appears to other disciplines and to the general public consumers of health care. Image and the perception of the profession impact recruitment of students, the view of the public, funding for nursing education and research, relationships with health care administrators and other health care professionals, government agencies
Nurses who are professional show and embrace accountability for their actions (Nursing and Midwifery Council UK, 2017). Professional nursing practice is important as it aids to maintain high standards in the clinical area (Hutchinson, D. 2017). If professionalism was not shown in nursing practice, it would lead to many issues. Professionalism can be shown by nurses giving patients autonomy which is a major characteristic of professionalism (R.G. Boss).
They are well trained and most communicate well and be able to instruct and teach the patient what care is needed after they are discharged. It is important that the nurse be genuine and compassionate to have a successful relationship with the patient. Conclusion These four concepts help the nursing profession to fully impact the patient and encourage a honest relationship and recovery.
I aim to be a nurse for the lifelong learning experiences that will allow me to grow and develop each day. As an interdisciplinary profession, nursing employs numerous duties beyond medical care. Critical thinking and creativity are vital to give patients the best treatment possible, as well as empathy and kindheartedness to display care and to promote comfort for patients and their families. Employing these qualities
The codes of conduct are a set of guidelines and rules you are expected to abide by in your healthcare role. Working professionally and sticking to roles is crucial for the effective care and successful healing of patients. Occupational therapists deal with patients in a range of settings, also working closely with relatives and carers for completed satisfaction, this means that the HCPC codes of conduct need to be applied at all times. Below is a list of the codes of conduct expected from an Occupational therapist The ability to remain professional at all times To continue with learning and gaining more knowledge in your area of