Accurate record keeping is very important for few reasons. First of all, different health professions are involved in patient care delivery and clinical process. All these professional have to communicate about patients and records is one of the best ways of doing it. Secondly, records reflect all procedures and manipulations with a patient in a chronological way so that members of staff know exactly the situation with patients to provide 24 hours care for patients. . Thirdly, accurate record keeping is important for investigating complaints and claims. The best care provided will not be counted if it was not recorded in patients notes (McGeehan 2007).
Records should be written briefly but informative at the same time. It should be focused on the patient, factual, measurable and realistic. It also should be written strait away after an event. The nurse should put date, time of the note and write her name. Handwriting should be easy to understand. The language should be appropriate without abbreviations or jargon. Poor note taking can be regarded as negligence (McGeehan 2007).
As every patient has different reasons for admission and different pathway on a ward, it is important to work out care pathways. It includes clinical risk assessment and outlining the care that this patient should be given recording to conditions. All members of the staff must sign when they use a pathway for a patient (McGeehan 2007). .
Trusts can be assessed by The Clinical Negligence Scheme for Trusts (CNST) by the way records were kept. As there are many complains and claims, every nurse should follow high standard record keeping so that records can be used as an evidence of care provided in a court (McGeehan 2007).
McGeehah R (2007) Best practice in record keeping. Nursing Standard 21(17), 51-58
Outcome 7. Informed Consent.
The concept of informed consent has been broadly discussed in medical literature. Indeed, gaining consent is very important for all health professions, including health care assistants, nurses and doctors. Medical process includes few documents where a patient signs his consent. However, in some cases the patient signs the forms without appropriate explanations. Or, explanations can be poorly understood by patient due to a difficult language (Erlen 2010).
Consent should be valid which means that the patient should be over 18, have the capacity and give consent voluntarily (Department of Health 2004). Any form of consent is valid, but only a written consent can be an evidence of the fact that consent was gained. Also, consent can be verbal and non-verbal, when for example, a patient holds out an arm for blood pressure to be taken (Department of Health 2004).
In English law no one has any right to touch another person without consent. As nurses deal with many patients daily, it is vitally to gain consent for every intervention. Additionally, a nurse should inform a patient about any procedure In some cases patients give implied consent. For instance, the same injection is given few times a day. However, it is important to gain verbal consent before every injection (Edwards 2010).
Department of Health (2004) Reference Guide to Consent for Examination or Treatment.
Erlen J (2010) Informed Consent. Orthopaedic Nursing. 29 (4), 276-279)
Edwards M (2010) An introduction to consent. Practice Nurse 39(6), 13-15)
Confidentiality is a core subject in health care. It is easy to lose patients trust by ignoring patients right to confidentiality. Confidentiality preserves personal dignity, prevents information disuse and protects autonomy of patient.
All professionals in health care have to communicate about patients and it is difficult to avoid information disclosure as at any times there can be unwanted listeners. For instance, when a nurse tries to make an appointment for her patient on the phone, she has to provide some information such as the name, age, address and a condition. There could be people near her at this point who will use the information.
Outcome 12. Signs and circumstances associated with aggression and violence.
Nurses they are reported to be at a high risk of dealing with patient aggression. Over 76 per cent of newly qualified nurses in South Wales for instance experienced patients aggression within first three months of employment. In most of cases the aggression was in a form of verbal abuse. Other forms of patients aggression are verbal or physical threats or intimidation and physical violence. As a result, nurses are at an increased risk of emotional suffering and depression (Hills 2008).
The research shows that female nurses experience aggression and abuse from patients more often than male nurses. It was suggested that nurses experience aggression and violence more frequently because they deal with patients more often than other health care professionals Mullan 2007)
What is more, some nurses have to take days off or sick time off after episodes of patients violence and aggression (Hills 2008).
The study shows that aggression management training programs for nurses could be an effective way to decrease incidents of violence in clinical area (Hills 2008).
Most of nurses who experienced violence or any form of aggression from patients reported that they were powerless avoid that and felt having lack of confidence (Mullan 2007).
Mullan B & Badger F (2007) Aggression and violence towards staff working with older patients. Nursing Standard 14(21) 35-39
Hills D (2008) Relationship between aggression management training, perceived self-efficacy and rural general hospital nurses experiences of patient aggression. Contemporary Nurse 31(1), 20-31