Examining nursing accountability in the context of record keeping

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Examining nursing accountability in the context of record keeping


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 individual nursing professional can be held responsible for the outcome of those actions  (Schwartz et al 2002; Hope et al 2008). In other words, it provides others with written evidence as to why certain events or steps have been taken by the nurse creating the written record, whether these prove to be right or wrong. Nevertheless, one definition that includes a more positive view on accountability is that “it is an innate certainty as an expert that permits a medical attendant to take pride in being straightforward about the way he or she has completed their practice" (Caulfield, 2005: 3).

Legislation and professional guidelines

From a legislative aspect, following a number of high profile healthcare failures, accountability has been embedded in the Health and Social Care Act 2012. Central to this legislation is the need for maintaining accurate recordkeeping by all healthcare professionals (HM Gov 2012). This is important because, as indicated in the Act [Section 104:3c], it is stated that the regulator has the power to demand documents “from any person who has provided, or is providing, a health care service”. 

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Consequently, it is apparent that if those records are found to be not complete or inaccurate, this will have serious consequences for the professional. Equally, as indicated in the NHS (2012: 1) advice on recordkeeping, the approach adopted by the courts is that “if it is not recorded, it has not been done”, which means that the healthcare professional may be held liable for any perceived failure. Equally, as noted within this guideline, the clarity and accuracy of the records will have a similar effect on professional accountability.

The importance of recordkeeping in relation to nurses also forms an integral ...

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