Why Good Medical Record Keeping Is important for Nurses

Organized and up-to-date medical records are a hallmark feature of skilled and efficient healthcare providers. However, sometimes allegations concerning shortcomings of nurses occur and so it is important for nurses to maintain accurate medical records to ensure best practices and also for legal requirements if any malpractice case arise. They must make sure that the health records of the patients are accurate and include all details regarding the services rendered. In health care units there may be a large number of medical reports that need to be transcribed. Competent medical transcription services can make the process of transcribing easier and quicker.

From a Legal Viewpoint

Litigation is considered as a major occupational hazard for medical staff, which has been increasing rapidly. Accurate records are important at the time of hearing and their absence makes it difficult for practitioners to prove that they have provided specific services. Nurses’ records should ideally contain the following details.

• A full account of nurses’ assessment and care planned and provided for the patients
• Relevant information about the condition of the patients at any point
• Measures the nurses had taken in response to the patient’s needs
• Evidence that the nurse understood and honoured the duty of care, and took all the responsible steps to care for the patients and that any action or omission has not compromised the patient’s safety
• A record of any arrangement the nurse has made for the continuing care of a patient

Nurses should clearly note down the services they rendered. This is because they face new issues and problems day to day and also due to the awareness of public rights and increasing tendency to litigate. They must allocate time for both patient care and also for documentation of the services provided. Good documentation can be a vital means of recollection of facts for nurses if and when they face litigation. Notes that are taken down during their course of work are potential legal documents. These documents help to maintain professional credibility.

When compiling records, the nurses should know that their colleagues rely on the information they recorded when giving care to a patient. Colleagues should go through nurses’ notes and ensure good care for the patients in a seamless continuum. If a nurse is unable to return to work, the patient should not be ignored and must be provided complete care. Nurses should ensure that if they delegate the record-keeping work to someone else, they are supervised and also make sure that the substitute care providers are capable of delivering their work effectively. All entries made in the patient chart should be countersigned.

Tips to Improve Medical Record Keeping

The following tips will help nurses eliminate unwanted problems related to medical record keeping.

• Use factual, consistent, accurate, objective and unambiguous patient information.
• Use quotation marks when required
• Use your senses to record what you did like I "felt", "saw", " heard" etc
• Write up notes as soon as an event is over and make subsequent alteration if required
• Ensure the records are accurately dated, timed and signed
• Mention if you have any objection about the care given
• Do not include meaningless phrases, irrelevant speculations and offensive statements
• Notes should be made with proper understanding and involvement of the patients or care giver

Maintaining accurate and up-to-date records has immediate and long-term benefits for both staff and patients. It also ensures that the professional and legal standing of nurses are not undermined by absent or incomplete records, if they are called for any hearing. Unambiguous and well-maintained medical records promote better communication as well as consistency, continuity and efficiency and reinforce professionalism in nursing.

Transcribing voice recorded files into medical records is important and it can be done with the help of a medical transcription company. These companies ensure maximum accuracy in their work. They have skilled medical transcriptionists who can provide quality and timely services at affordable rates. Partnering with a reliable transcription firm is the best option to streamline large volume medical records and maintain them safely.

Medical Transcription Services is a reliable medical transcription company in the USA, provides transcription to healthcare clients across the United States and worldwide.