RECORD KEEPING. (The concept should be defined and explored and an explanation provided of how this concept relates to the role of the nurse in providing care in your specific field of nursing)
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RECORD KEEPING. (The concept should be defined and explored and an explanation provided of how this concept relates to the role of the nurse in providing care in your specific field of nursing) - Essay Example
Record keeping refers to an automated or manual system responsible for collecting, organizing, and categorizing records to facilitate their preservation, use, retrieval and disposition. This system has four main components for its efficient performance. They include; records,…
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Extract of sample RECORD KEEPING. (The concept should be defined and explored and an explanation provided of how this concept relates to the role of the nurse in providing care in your specific field of nursing)
onducted to manage records, and tools in a record system comprise all the software and equipment used in capturing, organizing, storing, tracking, and retrieving records.
Keeping records is essential for the best functioning of any organization. Nursing being an important entity that supports human development and growth, it also relies on good record keeping for efficient delivery of services and health care (Luepker 2003). Therefore, it is the responsibility of every nurse in the nursing team providing patient care to play part in record keeping. However, a senior nurse overseeing unqualified colleagues should assume the responsibility and provide guidance on proper documentation. Keeping nursing records has many advantages, however, a majority of nurses struggle to find time to keep records. In addition to that, some of them do not view it as vital as other duties.
Nursing record entails the nursing care a patient receives, as well as his/her response to the care. Additionally, factors or events that may affect a patient’s well being are also recorded. These factors ranges from the patients’ visitors seeing them to scheduled theatre visits. In case a nurse does not know what to write down in a patient’s heath record, he/she should ask such questions as: “If I am not able to handover verbally to the next nursing team, what information should they know to continue giving heath care to the patients?” Answers to this question should give the nurse an insight of what she is expected to write in the patient’s records (Marsh & Magee 2009).
Good record keeping is part of nursing care given to patients. As a matter of fact, it is almost impossible to memorize everything one does or everything that happens in a shift. Therefore, failure to have accurate and clear nursing records for all patients may make handover to new nursing teams incomplete. Furthermore, this may affect the patients well being. Quality of records kept by a nursing department may be a ...
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