Every nurse needs to undergo health care mandatory training to know more about record keeping. This plays a vital role in the provision of healthcare services. Many team members are involved in providing care to a patient and all of them need to have accurate and easy to understand information about the patient.
A nurse who has undergone healthcare mandatory training in record keeping will execute this duty with ease and it will save the medical practice a lot of confusion and misinformation. Good records come in handy in case of any legal matters that arise.
Variation in Record Systems
The way different health care facilities keep their records may vary. The most common ones are:
- Computerized records
- Handwritten records
A nurse cannot choose their own system, they need to adapt to the system that the organization utilizes. Sometimes it could be a combination of both and that will require flexibility on the side of the medical professional.
Protection of Confidential Records
Naturally, all patient records are confidential and that calls for caution. If a computerized system is being used at the organization, then the nurse needs to guard passwords of these records. If the records are handwritten, then access to the record room should be restricted and nurses should not leave records lying in the open.
Common Guidelines for Record Keeping
The guidelines a nurse has to follow when keeping records are universal. They define good record-keeping and help to achieve the goals of record keeping. These include:
- Records must be legible and clear
- They must be written in ink that will not be erased
- The wording used should be universally understood as opposed to the use of jargon
- Patient information must be accurate and up to date
- Any changes to information must be indicated
- Every entry must have a date and signature of the author
- Patient’s information must include their name and other identifiers as stipulated by the organization
- Records must be free of any prejudice, abuse or assumptions
Sadly though, human error may sometimes result in poorly taken records. Names can be misspelled or updated information may be left out. A nurse needs to verify if they have correctly taken down information according to the guidelines.
Why Record Keeping Must be Taken Seriously
The well being of a patient depends on the information that is shared among those that are caring for them. Records ensure that different team members can carry out their roles even in the absence of the others. It also enables correct decisions to be made and problems can be addressed.
Record Keeping and the Law
Well kept records come in handy if any legal proceedings are instituted. They serve as proof that procedures were followed as well as shows if medical personnel played their part. In a court of law, medical records can be used as evidence. Medical professionals can use records to show no negligence occurred when dealing with a patient.
For records to be effective, nurses need to learn how to take them according to a set standard. At no time should they be ignored since it is not just for the benefit of the patient but also for every member of the medical team. It is also important that they are kept safe.