Good record keeping, whether at an individual, team or organisational level, has many important functions, including helping to improve accountability, supporting the delivery of services, supporting effective clinical judgements and decisions and helping to identify risks, and enabling early detection of complications (Dimond 2005).
Like the implementation of health and safety regulations, it is not easy to ensure that there is always a reasonable standard of record keeping: there are peaks and troughs depending on the priority given to record keeping and the competing pressures for the time of registered practitioners.
The patient’s re-presentation the next day also highlights the breakdown in communication between the patients General Practitioner, the Career Medical Officer and Medical Registrar.
It is important that collaboration occurs between health professionals to ensure a seamless flow of work based on knowledge of the patient and their care (Stein-Parbury & Liaschenko 2007).
However, it must always be remembered that records and record keeping are an intrinsic part of the professional activities of a registered practitioner, not an optional extra.
The coroner report investigating Mr Gillam’s death does not specifically question the ethical decision-making of either the nursing or medical staff; however I believe that some questions should have been asked.In this case the communication between the Career Medical Officer and the patient’s General Practitioner was either ignored or overlooked as unimportant.It is vital that if the patient’s history did not match that of the General Practitioner that communication should have occurred to clarify these issues.The most significant documentation practice is to actually write something. It should be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient.It should identify problems that have arisen and the action taken to rectify them, providing clear evidence of the care planned, the decisions made, the care delivered and the information shared (Nursing and Midwifery Council, 2004).Contributing to this mans death the Coroner found the following: lack of communication and failure to properly convey true the situation of the patient between the Emergency Department Career Medical Officer, the Medical Registrar, and General Practitioner; the lack of understanding by nursing personnel regarding after hours access and cost for procedures that present to the Emergency Department; And a Medical Officer with little experience as a clinician performing the role of Career Medical Officer.The coroner highlighted in this case that poor communication both verbal and documented contributed to the death of Mr Gilliam.Communication requires that participants share a mutual interaction, with the receiver providing feedback to the sender. 3) states that nurses must be effective interpersonal communicators which is defined as “…interactions with patients which are helpful to the patients”.This first contact was not effective communication.Secondly the communication between the Medical Registrar and Career Medical Officer was also shown to be lacking.If communication tool such as SBAR (Situation-Background-Assessment-Recommendation) was used it may well have eliminated this problem by improving communication between clinicians.