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confidentiality ethical dilemmas health care
ethics and confidentiality in healthcare
confidentiality ethical dilemma in healthcare
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The nursing program is a three year intensive program of a mixture of both practical and theorical aspects of nursing. It is a very demanding program that requires patience, courage and passion. Very early in the first year, we are sent to the hospital where we deal with real patients that are very illed. As we are thought, nursing is not a career but a profession where learning is an ongoing process that has no breaking point. It is a complete pleasure for me to be a part of this program. As a student nurse, it can be stressful to be ‘handed’ the life of patients but the program is specifically made in a way that you have all the skills needed to care for patients. One of the very chief skill is charting. Charting is a type of documentation …show more content…
Charting plays an important role in the nursing program by enabling safe and effective patient care (Lewis 15). Likewise it can also be closely associated and differentiated to memoirs in terms of communication and privacy.
Charting is an essential part of nursing care. It is a tool that provides ongoing information of the health of patients from the progress notes of nurses. It is also used as a mean of communication between health care professionals involved in the care. For example, most of the doctors do not have the time to do an overall assessment of each patient when they come in the morning, this is why they read the charts and from this they can get the baseline of patients and know which problem they have to focus on. In like manner, nurses from the next shift use these charts to know what to keep an eye on during their stay. Charting is very crucial in keeping patients alive
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Unlike charting, memoirs are very public and available to all. On the other hand, is a very private document that is accessible to only the health care professionals involved in the care. Even the family members are not allowed to see the charts. It is very confidential and a nurse could get her licensed revoked if she reveals information that is inside the chart. In addition, memoirs can sometimes be dishonest or a version of the truth. While charting must remain accurate. Any false information can result in suspension of license until fragment is repaired and explained. Plus, memoirs are mostly from childhood but charting is from a near past or current medical condition. Charting is written from the point of view of the nurses and other health care professionals while memoirs are written by the same person emphasized in the memoir. The patient is not allowed to write in the chart or even see it .It is strictly only for the health care professionals. Withal, there is a variety of distinctions between memoirs and
Nursing is a little like a stage production. Success is determined by everyone working together. If someone does not record accurate information on a chart, serious consequences could occur. The team of professionals is only as strong as its weakest link. Just as I go on stage relying on others to know their lines as well as I do, as a nurse I will go into emergency situations relying on others to know their jobs; lives depend on it. I have enjoyed my experiences on the stage and sincerely feel that this experience helps me develop skills that will assist me in my nursing career.
Documentation has been explained by so many authors and many studies have been done concerning it. According to Kammie Monarch JD,R.N. Documentation can protect nurses against allegation of negligence and malpractice, preservation of medical records and mistakes commonly made in charting that leave nurses vulnerable to law suit.
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
chartings in the medical record of a patient, taking the patients vitals and reporting abnormal to
Working as a professional registered nurse in the hospital, I realized how nurses struggle to find balance between devoting the time charting on the computer and spending time taking care of the patients. Moreover, I’ve seen nurses where they get discouraged trying to find this balance between patients and charting. As a bedside nurse, I would love nothing, but to tend to the needs of my patients. The length of time consume on electronic charting all day, take the very essence of bedside nursing away from nurses, which is caring. Reducing the time of nurses being occupied on charting by eliminating redundant tasks while conforming to their standard, are the changes I would like to make. These are a few of the reasons why I wanted to pursue a degree in informatics. I would advocate for nurses everywhere and to become an instrument in providing them a better electronic health system to work on. Pursuing the degree in nursing informatics will benefit me in
The authors consist of nurses, specifically: a Chief Nursing Officer, a Nursing Informatics Officer, and a Dean/Professor of Nursing at Belmont University. The article described how vital nursing documentation is to achieve optimal patient care, including improving patient outcomes & collaborating with other healthcare providers. Using Henderson’s 14 fundamental needs as a framework for their research, the authors proved a definition of basic nursing care and incorporated it into an electronic health record. The authors utilized a team of 16 direct care nurses who were knowledgeable with documenting ele...
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
The career of a registered nurse is one of the most interesting professions in the medical field, because not only do they help to improve the health of their patients, they also help their patients to maintain a healthy lifestyle. Registered nurses work to promote health, prevent disease, and help patients cope with illness. Their job is to help patients get their health back on track, and prevent increased visits to the physician. When providing care directly to the patient, they observe, assess, and record symptoms, reactions, and progress. They do this to see where the patient’s health stands and prevent further illness or health problems if such occurs. Registered Nurses help to develop and manage nursing plans, and instruct the patient and their
The purpose of the paper is to discuss the activities involved during the evaluation of a patient. Evaluation of a patient can be seen as the process of examining a patient critically. It comprises of gathering and analyzing data about a patient and the illness (Allan, 2012). The core reason is to make judgment about the disease one is suffering from. Such judgment will guarantee proper treatment and diagnosis. Typically, gathering of information from the patient is the role of nurses while making judgment and prescription is the doctor’s role (Jacques, 1988). In any case all practitioners are required to know how to evaluate a patient.
Craig, S. & Lloyd, S. (2007). A guide to taking a patient’s history…clinical skills. Nursing Standard, 22(13), 42-48.
The medical field is filled with many rewarding jobs and one of those jobs is being a nurse: the job of taking care of people who are sick, injured, or old. Seems like a pretty easy task doesn’t it? Nursing takes time and skill to learn, but a lifetime to perfect it to the best ability anyone can. Being a nurse is one of the
To effectively use the Electronic Health Record, the nurse needs to have knowledge of technology in addition to clinical competency (Linder, e.tal, 2007). This is a common barrier of implementing the Electronic Health Record. Initially, the conversion from paper charting to electronic charting is frustrating, this is particularly an issue for veteran nurses. Veteran nurses are use to a routine, documenting in pen and paper is the only method of documenting they have ever experienced. Nurses are trained and educated with a protocol-based and systematic methods of caring. The implementation of the Electronic Health Record presents a change in the way nurses care for patients (HIT, 2015). Veteran nurses that have worked in the healthcare system for over 30 years and have always used paper charts, now have to re-learn how to chart with the Electronic Health Record (Anders & Daly, 2010). Understanding the nursing related barriers of implementation of the Electronic Health Record is
Technology is stated as the scientific method and material used to achieve a commercial or industrial objective. To go one step further, nursing technology is using a tool to advance nursing practice. “The Institute of medicine identified that technology as a viable method of enhancing patient care delivery and improving staff productivity” Sensmeier, Horowitz (2003 page). Because inadequate nursing staff causes shortcuts to be taken, there are mistakes made that could have possibly been prevented. Errors by nursing staff were variously reported as being responsible for between 44,000 and 98,000 hospital deaths per year. Sensmeier, Horowitz (2003). Technology can have a large impact on nursing. In the past 5 to 10 years, computerized patient records have increased less than 10%. This number shows us that we are still not embracing technology to its full potential. Today in most hospital systems computerized electronic charting is being used. Many hospitals have many different systems for...
William Goossen’s theory can be applied in nursing practice to develop nursing informatics skills and knowledge, as well as develop technological system competencies among nurses to collect, process, retrieve and communicate pertinent information across health care organizations (Goossen, 2000). This theory is highly applicable in addressing matters related to electronic health records, which are currently characterized with issues of privacy and confidentiality in relation to storage, retrieval and reproduction of patient health information. The model also provides broad applicability in guiding research at any clinical setting and contributes to the discipline of nursing by simplifying and enhancing documentation and storage of patient’s health information and by allowing better utilization of nursing resources (Elkind, 2009).