Reflection and Witness
Today I was asked to support and care for a patient Mrs Y as we had noticed over the past weeks she was losing weight and following dieticians referral we were asked to give a certain diet and supplements for that patient and monitor her intake and output by doing a food chart, fluid chart and stool chart at food times and when needed to help her gain weight. As we were monitoring her closely it was important that we handled the information carefully and sensitively and insured that all the records where up to date completed fully and accurate and libel. We do this to ensure the records are continuous records of what actually happened. We need to have records complete to make sure that the monitory is taking place. Has to be accurate and allegeable to show what staff have found. We are required under the data protection act and freedom of information act that if we write it has to be in black ink and clear to read. As I have been looking after Mrs Y I made sure I was recording the information accurately, legible and completely on the correct documentation so everyone can follow. In my area of work we keep the patients folder at the bottom of the bed, any sensitive information is put into the office which is locked. I make sure when people put information onto patients records on the computer it is password protected and away from full view from others. I know that I can only share information with patient’s full permission. Mrs Y daughter came in and I referred her to the trained nurse as she was asking about Mrs Y care. When completing records in required ways you need to make sure you enter the correct information and that it is understandable for all staff to read. It needs to be in black ink at all times. This needs to be in black ink so its dark enough to be photocopied if necessary in the future, also it’s in accordance with Trust record-keeping policy and Nursing and Midwifery Council record-keeping standards. When...
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