Identify a core principle from the NMC Code of Conduct (2008) and demonstrate how this may affect professional practice
This essay contains discussion on the importance of proper documentation and record keeping as a core principle of the NMC Code of Conduct. The report further highlight how this may affect professional practice and the implication of poor record keeping practice.
Medical records are the most basic of clinical tools (Pullen and Loudon 2006) and their main importance is to serve as a form of memoir or aid in client and patient support. Medical records therefore provides essential evidence of care provision, thereby enabling effective communication between health care professionals, members of the multidisciplinary team and all clinicians as a whole.
One of the main expectation from all Nurses and Midwives as laid down in the NMC Code of Conduct (2008) is that all Nurses and Midwives must keep clear and accurate records. The Department of Health’s (DH) policy statement on record keeping also place a responsibility on all health professionals to ensure that all records created and maintained are accurate, current, comprehensive, concise and legible. Such records should also provide information concerning the condition, treatment and care of the patient and associated observations (DH 2002).
However, for any medical record to serve the purpose for which it is meant for, it has to be “contemporaneous, unambiguous, legible and accurate” (Dimond, 2005). Accuracy of records could be described as the most important factor when it comes to record keeping practice in nursing. This is because accuracy in nursing records and documentation provides a real timeline information of the various stages of care provision. Prideaux (2011), suggests that accuracy in record keeping entails maintaining adequate record of events in a sequential order and keeping information about patient care in chronological order.
Furthermore, it is important to make sure that not only does a medical record contains the right information, effort should also be made that such information is written in appropriate and meaningful language(Pirie,2011). Care should be taken especially when using abbreviations so as not to present a misleading...