Record Keeping Role In Nursing

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The aim of this assignment is to explore the understanding of the role of a nurse in relation to record keeping in nursing to ensure a safe, high-quality and continuous nursing care to the patients. Nursing documentation is a fundamental aspect of a nurse’s obligation in everyday clinical practice (Griffith and Tengnah, 2010). The importance of record keeping will demonstrate the best practice in nursing by focusing on four key areas of nursing practices to ensure and to maintain the assessment of patient’s records, continuity of care, prevention of medication errors and evidence for court cases.
The purpose of record keeping allows to keep a record of patient’s condition, treatment, medications and progression of their care by highlighting
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The legal implications on records allow any documentation that records any aspect of the care given and involvement with patients to be used as evidence in court (Griffith and Tengnah, 2010). Therefore, nurses must record a detailed account of demonstrating the duty of care received by patients (Griffith, 2015). Documentation allows to prove the care given to the patients (Griffith, 2015). Having all things considered, it highlights that failure to maintain record keeping can be used as evidence of nursing malpractices (Diamond, 2005). Information about care that hasn’t been recorded suggests that the care wasn’t given to the patient (Hand, 2014). Good record keeping will indicate the nurse’s legal and professional liability and discharged duty of care to the patient (Griffith and Tengnah, 2010). Incidents where poor record keeping can allow colleagues and other health members to harm a patient, subsequently this could develop into a legal issue and might result in a charge of professional negligence (Wood, …show more content…
Record keeping allows nurses to ensure the care received by patients is safe and of a high standard (Beach and Oates, 2014). In brief, the most essential aspect of record keeping is the completion of the duty of care to the patient and other nurses who are responsible for caring are fully aware of the patient’s records to take on actions (Diamond, 2005). The ongoing nursing record keeping helps to inform colleagues about what has been done to the patient and facilitate effective communication between team members ensuring high quality care to the patient (Diamond, 2005). It is needed in the administration of medication to prevent errors and also to provide documentary evidence of the quality of care received by the patient which helps for legal

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