Effective record keeping is an essential task in health care so it should be handled keenly and professionally (Grace 2017). The records should be both accurate and detailed so that they can be used in monitoring a patient’s health progress and designing effective treatment methods. Legally patients’ health recording keeping also helps in protecting the practitioners when they require legal defense of something they have done. Law courts assume that a health action that is not recorded was never undertaken.
Health records are also vital in establishing whether services have been improved to address the health concerns recorded. As per the Code of Professional Conduct, health practitioners must ensure that the information recorded is as per the treatment, plan of care as well as delivery (Grace 2017). However, the health practitioner should record the information in the presence of the patient and with his/her consent.
One of the ways that recording and reporting can be improved is by adopting a computer-based patient record. Once one practitioner captures information, it will be electronically sent to other practitioners who will attend to the patient (Grace 2017). It will also be significant to ensure that practitioners are not overwhelmed with patients because if a practitioner has one hundred cases to handle he/she might fail to document the patients’ details or may do so incorrectly in a hurry.
For information to be disclosed to a third party, the patient must provide consent. To ensure that there is disclosure and consents practitioners will be advised to inform the patients the purpose of disclose and which information will be disclosed (Grace 2017). The consent must be in the form of writing and filed so that there can be evidence that the patient agreed on the information to be shared with a third party. Implied consent is however assumed if the medical examination was done based on the request of a third party.
Grace, P. J. (Ed.). (2017). Nursing ethics and professional responsibility in advanced practice. Jones & Bartlett Learning.