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Examining nursing accountability in the context of record keeping

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Transfer-Encoding: chunked ´╗┐Examining nursing accountability in the context of record keeping ________________ Introduction The aim of this essay is to improve nurse awareness of the issues related to accountability in health and social care settings. Accountability refers to the legal, professional and ethical guidelines that underpin the responsibility of nursing professionals working in health and social care environments (Caulfield 2005; Carvalho et al 2011). Specifically, the essay will examine these accountability factors as they relate to recordkeeping by nurses within the healthcare sector. Defining record keeping accountability in the context of health and social care Recordkeeping in the context of health and social care is a process through which the actions taken by nursing professionals in their role to cater for the health and medical needs of the individual patients are documented (Jones 1996). This written documentation is therefore accessible to any other stakeholder involved in or affected by the healthcare service provided, which includes the patient and more important, senior managers and regulators (Tilley and Watson 2004). Taking into account these objectives, it is apparent that the healthcare professional responsible for creating these records is accountable for ensuring that accuracy of the data and information they contain (Caulfield 2005). Accountability is generally considered to provide a justification of the professional?s activities and action in terms of the care provided to patients, and a means by which the ...read more.


This is supported in the research conducted by Griffith and Tengnah (2010) which recognised that a nursing professional is legally and professionally liable for his/her own personal conduct irrespective of the actions of others. This includes working as part of a multidisciplinary team and being focused on improving the health and wellbeing of the patients relying on their care (Rumbold 1999; Swartz et al 2002). Beauchamp and Childress (2008) offer four rules that they consider important for the foundation for moral leadership in nursing, which consist of Autonomy, Non-wrathfulness, Beneficence and Justice. They consider these four standards to lie at the centre of nursing performance. Essentially, this means that the nurse should be guided by his/her own moral judgement and not only ensure that no harm should be caused to a patient either purposefully or intentionally, but also that the patient receives the quality of care that he/she justly deserves. In this respect, justice is about treating people decently and similarly and obliges the nursing professional to be non-judgemental. Additionally, as suggested by the NHS (2010), this ethical approach should be focused on providing the patient with the opportunity of involvement with the decision-making and choices related to their own care, Recordkeeping is important in this respect, in that it allows the patient access to an understanding of the care being provided. ...read more.


Accuracy of the recorded evidence is particularly important in healthcare situations, as it will enhance the quality and appropriateness of the healthcare intervention being provided for the patient. Moreover, good practice in recordkeeping and compliance with the guidelines provided will have a positive impact on the issue of accurate and meaningful accountability (Caulfield 2005). Conclusion The discussion presented in this essay confirms that recordkeeping is a process in healthcare that is used not only for the purpose of effectively sharing information, but also as a process that ensures the nursing professional can be held accountable for his/her actions. However, providing the actions are recorded clearly and correctly, and is supported by the evidence, it is a process that also clearly defines where the boundaries of the professional?s accountability exist. More importantly, recordkeeping accountability is the process through which managers and other healthcare team members can be assured that the patient has received the quality of care to which they are entitled, and in this respect, it also serves to reduce the risk of medical and clinical failures. Consequently, despite the practical challenges that may affect the recordkeeping process, it is important for the nursing professional to ensuring that they maintain an accurate and transparent approach to recordkeeping, which must be based on the facts and not their individual personal interpretation of the events that have occurred. Good practice in recordkeeping enhances accountability and it should therefore should guide nursing conduct in the healthcare environment. ...read more.

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