4. ANÁLISIS DE LA ARQUITECTURA PROPUESTA INCLUYENDO SDN Y
4.2 Comparación de la arquitectura propuesta con soluciones
What you are doing What you say
Picking up the phone and identifying yourself
Helping the caller
Asking for identification and information
Explaining that someone is not available
Suggesting alternative actions Confirming
Declining information Responding to thanks Signing off
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7.3
Record keeping
Nurses are normally concerned with writing notes for reference purposes to keep up the medical records. However, the NMC state that:
They place emphasis on sharing of knowledge for the benefit of the patient. Sharing can only be effective if information gathering and recording is of a high standard.
As you will know in most clinical areas there is not just a single document but many documents which must be maintained, although in some hospitals multidisciplinary documentation is being introduced.
There is a wealth of clear cut advice about the legal aspects of record keeping. Because you need an awareness of laws such as the Human Rights Act 1998 and the Data
Protection Act 1998 employers usually familiarise their employees with the essentials in their induction programmes.
Patients are increasingly exercising their rights to access to records and to comment on their treatment. In some instances patients hold their own records. In a legal case your records are a major part of the evidence. ‘Under the UK legal system, a patient may bring a case for negligence up to 3 years after the event.’ (Watson, 2002, Clinical nursing and related sciences, page 12)
Remember you are accountable for your actions and so need to document them – even where you decided not to take action this should be documented!
The NMC Code of Professional Conduct states that nurses
The NMC criteria
• Documents should be written as soon as possible after the event has taken place • If possible the patient should be involved in their completion
• It should show evidence of how care is
decided upon planned
delivered evaluated
The NMC’s comprehensive leaflet Guidelines for Records and Record Keeping (2002) is essential reading.
Healthcare records are a tool of communication within the team.
NMC Code of Professional Conduct page 6
must ensure that the healthcare record for the patient or client is, ‘an accurate account of treatment, care planning and delivery.’
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Language study unit
The next exercises invite you to reflect on the content, accuracy and style of your own record keeping.
7.3.a
Is there any aspect of your written English that could be improved? Tick as necessary.
Accurate English grammar e.g. use of tenses, prepositions Neat handwriting – is it easy for others to read? Expressive language – do you ever find yourself searching for the correct word or think that you could have used a more suitable word/phrase? Too dependent on abbreviations and acronyms? (The NMC say that they should not be used at all) SpellingIf you are unsure about your self-assessment ask your mentor or
Brilliant
buddy to help you. Perhaps you could write a mock patient report and ask them to help you assess its strengths and weaknesses.Using your checklist decide on an action plan for improvement. For example:
Spelling
I will use my dictionary more often. When I put a new word or phrase in my lexicon I will
check it when I get home When I’m on the phone I will ask the speaker to spell long words out for me
I will use a spell checker on the computer when I type a
document, then I’ll make a note in my lexicon of the correct
spelling
I will ask my friends to tell me if I have spelt something wrong
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7.3.b
Choose a document with handwritten notes.
Using the checklist below and the NMC’s criteria above evaluate the document.
Describe the document.
Does it have the following features?
Legible
In dark permanent ink
Any errors crossed through with a single line, dated and signed
Signed, dated and timed
Factual (not subjective)
Has evidence to back up any decisions
Free from jargon
Free from abbreviations and acronyms
Gives a picture of what the nurse did, heard and observed
Reports actual phrases that were said by a patient or colleague Refers appropriately to any other documents such as care plan, observation charts etc.7
Scope of practice unit
7.4
The legal framework
Caulfield* usefully divides regulation in healthcare into two main branches, ‘objective rules’ and ‘subjective rules’. Subjective rules are social, moral and personal choices made by the nurse. For you, as an international nurse with your own beliefs, values and cultural frameworks, it may be necessary to be sensitive to the accepted norms of the society and culture of the UK as well as reflecting on your own professional standards. Objective rules are defined as, ‘Being imposed, enforced and obligatory and frequently applied to areas of professional work where a clear statement of guidance and control is required for reasons of safety and public policy.’ Examples of these are
• Your Code of Professional Conduct
• English (or Scottish) Civil Law (including vicarious liability) • English (or Scottish) Criminal Law ( slightly different in Scotland) • Accountability to the employer
It may seem a little frightening to be faced with so much new important information. You must understand the seriousness of breaking (or bending) rules or laws – you could be putting your professional registration at risk as well as your patient. But, equally important, you must be appropriately supported by your employer to minimise the risk of breaking the law out of ignorance – because you didn’t know better – this is where the emphasis on training days comes from.
In addition there are situations where there are no clear legal guidelines. So exercising your professional judgement is critical! Better still is checking your professional judgement against those of your colleagues – would they understand and agree with your actions?
* Caulfield H. The legal and professional framework of nursing in Balliere’s Nurses’ Dictionary, Balliere Tindall & RCN, (2002) page 487
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