Importance Of Record Keeping In Nursing

Submitted By elvis98
Words: 546
Pages: 3

THE ACCOUNTABLE PRACTIONER | Record Keeping | MODULE: B72S05 | | Cohort: 10/09 | |

Student ID: 21018 Assignment: Using the learning diary and group activities as resources, critically appraise the learning that has taken place during the module in respect of your development as an accountable practioner. |

CARE DELIVERY AND MANAGEMENT

MODULE: B72M17
COHORT: 10/09
STUDENT ID: 21018

Contents: Pages:
Essay……………………………………………. 1 – 5
References……………………………………. 6 – 8
Appendices …………………………………… Diary Sheets
In this essay, the author will explore the issues of record keeping and confidentiality. Nurses are subject to ethical, legal and professional duties which are considered to be to respect patient's confidentiality. The author will discuss about the development of Griffith and Tengnah (2008) "states that maintaining confidentiality of patient's information is a fundamental element of professional conduct and ethical practice for nurses". The reason why I chose this incident is to explore the professional components of the incident that occurred during my clinical placement and to see how patient's information can be maintained and the importance of record keeping. Patients' information is identifiable because of their name, date of birth, address and postcode. A nurse must ensure that all confidential information obtained concerning patients must be protected and disclose only with patient's consent (Rumbold, 2006). In order to respect the staff name's to confidentiality I will use a pseudonym to protect the patient and nursing home staff information (NMC, 2008). My pseudonym is Mr TC for the patient and Mr Anthony Adams. Pseudonymisation is a process that aims to provide a confidential solution to service users that are known to Trust (SLAM, Confidential Policy, 2010). DESCRIPTION I will discuss nursing professional issues of confidentiality and record keeping from different perspectives including nursing code of conduct, local Trust and national policies, common law applied to professional practice and ethics and other literature. Nurses have legal and professional responsibilities to respect the rights of patients and to treat them equally. Patient's records are to be kept confidential at all times. When a nurse accesses the patient records, the nurse is not to discuss the patient's conditions or any other confidentiality information with anyone not assigned to care for the patient. According to