Clinical Record Management Policy Essay For Nurse Manager.

Job Role Description and Policy Relevance

Task: 1

1). Where did you source the policy and procedures that you accessed for your review?
If possible, provide a link to where these documents are published on the Internet or upload a copy as a separate file with this assignment. Detail how you searched for and found these documents.

2). What is the job role that you are detailing and the policy you have chosen for an in-depth review?
How is that policy relevant to the work responsibilities the job role detailed?

3). For the policy of your in-depth review, outline a situation that could occur if the related procedures were not performed correctly or if there was another type of failure scenario related to the policy. What could be the consequences of a policy breach? Should such an incident be reported? How?

Task 2

2.1). Effectively washing hands is a most important consideration for those working in a healthcare and community services workplaces, it is also relevant information for the general public in maintaining good health. For this task you are required to produce a guide, brochure or poster that relates to how to effectively wash hands. Your document needs to be designed to:

• Be useful to healthcare and community services staff and also the general public
• Be written in simple English so that it can be easily read and understood
• Be supported by images and/or links to videos that demonstrate effective hand washing.

You can include details for personal protective equipment (PPE), such as gloves, if you wish.

You will find useful information and resources from the website of Hand Hygiene Australia:

http://www.hha.org.au 

2.2).There are a number of means by which you could circulate your hand hygiene document. Consider a communication platform that may be in use in the community or health services and explain how you would circulate (and possibly revise) your document for distribution via digital media (such as website or intranet, social media, podcast or video channel etc.) Are these any organisation policies that may need to be considered in the process of publishing the digital communication?

Task 3

Locate a copy of the role or position description (PD) for your current work role or look for a position description for a healthcare or community services work role that you are interested in. Upload a copy of the position description with this assignment. You may be able to find a relevant position description:

• By asking your manager, supervisor, administration or Human Resources office
• On the website of a State Health Department or other health or community services
• By performing a job search for the role and finding an advertisement with PD
• By contacting a health or community service where the role exists and requesting a copy
• On the website, or by contacting, a relevant professional association for the job.

3.1) Does the PD include information that details the industry and related award for the role?
Where else could you go to find relevant information for industry standards and award rates?

3.2). List one of the responsibilities of the role detailed in the PD that would have legislative requirements or accreditation standards that apply. Provide a link to the standards and/or detail what they are.

3.3).What other healthcare professionals would this work role cooperate with in performing the job responsibilities? Would this include dealing with different levels and sectors of the health industry?

3.4). What type of issues could be encountered in performing the duties of this work role? What would you do if you identified an area of improvement with how the organisation handled a certain issue?

3.5). What type of personal skill maintenance or development would be relevant to continuing in this work role? Where would you access information or advice on how to set goals and plan for skill and knowledge development in the role? How should future work goals be focussed?

Task:1

1.1) Good clinical record keeping is an important part of the professional medical practice which supports evidence based practice. In order to ensure the accurate presentation of clinical records, the department of health should be committedin fulfilling the legislation and regulations described in the Public Records Act of 2002. The policy of clinical report management was sourced from Queensland Health. The link for the page from which this was taken is provided: 

1.2) This policy provides standards regarding the management of clinical information and assure the consent with the national and legal requirements. The major principles of the policy include proper managements and preservation of the clinical records, best practice is allocated for good recordkeeping, the records are accountable hence are regularly monitored., security provision should be implemented in order to maintain the integrity of the records and finally the records should be managed in such a way that there is no trust issue. The clinical reports may be paper record or electronic record. Any sort of record in diaries, incident forms, attendance books, messages related to care of a patient and clinical lists come under the list of paper records. On the other hand the electronic record is a much more secure, real-time and centric information resource. The electronic patient record (EPR) is kind of an official health control record of an individual patient which can be shared in between multiple departments of the organizations and agencies (Anon 2018).

For this paper the policy of clinical report management was selected which is in relevance to the job role of a nurse manager. This policy of clinical record management is applicable to all the staffs who are engaged in providing care to the patients. All the employees should have a thorough knowledge of the policy statements. The clinical staff should be responsible for keeping their own record as is detailed in the record keeping policy. Being a nurse managerit becomes all the more important to document good clinical notes related to the medical history of the patient. This helps for future references of clinical information. While record keeping, the nurses should also follow the legal obligations of accuracy of the record content,confidentiality of the record and patients’ access to their reports, as is stated by the records keeping policy (Hendricks and Cope 2013).

1.3) Confidentiality breaches often occur due to lack of hospital organization and infrastructure. Healthcare personnel may be also be involved in such breaches. In any case of breach of the policy, where the organization fails to comply with the legislation, actions are taken such as fines, imprisonmentand loss of position and reputation.In cases of minor breaches which include improper handling of the reports,, the consequence leads to the custody of the clinical historians due to lack of hospital infrastructure. In cases of severe confidentiality breaches, where the records are revealed to the third party measures severe should be taken like loss of position of the health personnel or the hospital administrator (Hendricks and Cope 2013).

Consequences of Policy Breach

Task:2

2.1) You are not being assessed on the artistic quality of your images, you can copy images from the Internet or other sources if that helps.

Your document can be simple, but must be clear with information that is well communicated and easy to understand. Keep in mind that you have a diverse audience, consider individual and cultural differences in your design. Your document could be a Word, PDF or image file.

You can copy and paste or insert your document below or upload it separately with this assignment.

                                                             

2.2) Printing of posters or distribution of handmade brochures were the traditional methods of hand hygiene promotion strategies. The recent “Net generation” no more believes in the same therefore platforms like the hospital website, the hospital group email system or social media like Facebook, Watsapp and LinkedIn. Campaign studies carried out showed that the promotion on Facebook was most successful than the other platforms. Other web page interventions can be carried out to promote hand hygiene along with issuing of video clips on the internet (Luangasanatip et al. 2015). Although in order to carry out such social media promotions, the employees of the organization have to follow the social media policy. The terms of the policy includes that the employee should avoid engaging in comments or discussions regarding the company especially in the company related websites. Meaningful updates should only be posted which should maintain the patient privacy. Before engaging in such actions, the employees should have knowledge regarding the Company Confidentiality Agreement. According to this these can be posts of the images of employees, the providers or the patients of the organization without proper authorization (Ellingson et al. 2014).

Task: 3

3.1) The position description of the job role of a nurse manager does not entail the industry and award for the role. In order to find relevant information regarding it, the website of Industrial Court of Queensland and Queensland Industrial Relations Commission was visited.One of the responsibilities of a nurse manager is to overlook that the regulatory requirements are being maintained which includes all regulations in context of the state, the federal and the local regulations. This role requires legislative standards which needs to be applied by the nurse manager. The link provided contains the legislation standards relevant to Nurses’ practice: 

Hand Hygiene Guide, Brochure or Poster

3.2) Following are the legislative standards in the context of nurses’ practice: Access to Abortion Services Act, Adoption Act, Adult Guardianship Act, Assisted Human Reproduction Act (Federal), Child, Family and Community Service Act , Community Care and Assisted Living Act, Continuing Care Act,  Controlled Drugs and Substances Act (Federal), Coroners Act,  Criminal Code (Federal), Criminal Records Review Act, Divorce Act (Federal), E-Health (Personal Health Information Access and Protection of Privacy) Act, Emergency Program Act, Employment and Assistance for Persons with Disabilities Act and Employment and Assistance Act, Evidence Act,  Family Law Act, Freedom of Information and Protection of Privacy Act (FOIPPA), Good Samaritan Act, Gunshot and Stab Wound Disclosure Act, Health Care (Consent) and Care Facility (Admission) Act,  Health Professions Act, Hospital Act, Human Rights Code, Human Tissue Gift Act, Infants Act,  Laboratory Services Act , Limitation Act  Medicare Protection Act , Mental Health Act , Motor Vehicle Act , Ombudsperson Act,  College of Registered Nurses of British Columbia,  Patient Care Quality Review Board Act,  Patients Property Act, Personal Information Protection Act (PIPA), Personal Information Protection and Electronic Documents Act (PIPEDA) (Federal),  Pharmaceutical Services Act, Pharmacy Operations and Drug Scheduling Act, Power of Attorney Act, Privacy Act, Public Guardian and Trustee Act, Public Health Act, Representation Agreement Act,  Representative for Children and Youth Act,  School Act, Vital Statistics Act and Workers Compensation Act(Crnbc.ca 2018).

3.3) As a nurse manager, the role is diversified therefore it requires interaction with other healthcare professionals who are involved in care giving to the patients. There is a need to oversee the workflow, training and development of the employees of the department. Services needs to be organized in consultation to the organization administrators. Committee meetings, medical staff meetings are needed to be organized by interacting to the staffs (Hegney et al. 2013). The customer satisfaction scores also needs to be monitored and plans are to be made to implement efficacy in service provision. Responsibilities are also needed to be taken to investigate the patients, the doctors and the other staff complains and grievances and should work in order to resolve them. All these roles can be carried out only if there is proper interaction on the part of the nurse with the other health personnel and the higher authorities of the hospitals or healthorganizations (Scully 2015).

3.4) According toNardi and Gyurko (2013), a nurse manager has to face challenges when performing this role are several. This included proper staffing of the respective unit, keeping the staff engaged with work, managing the behaviours like performance management. Additional challenges include financial understandings of the budgets and variances, Maintaining work-life balance, recruitment and retention of the unit staff, dealing with the patient families, working in a complex organizational hierarchy and lastly dealing with too much organizational change.

Circulating Hand Hygiene Document via Digital Media

There are several scenarios which call for improvement in the hospital management strategies. On such problem is that of process management. In order to implement improvements in this field, a systematic approach should be adopted towards it. The hospitals fails to understand the standards of the performance and controlling the system failures, which should be the prime focus (Staats2016). Most problems are created out of the inadequate system design issue which can be solved by redesigning the system design with better connections and understanding the root of the problems. The changes required in the management needs to be addressed and quality improvement is to be implemented.

The skillsets which needs to be maintained by a nurse manager in order to carry out the job role efficiently includes knowledge of emergency medical services, strong organizational and interpersonal skills, the ability to determine relevant course of action in complex situations, need to work independently by maintaining the positive attitude. Along with these there should be ability to maintain confidentiality regarding legislative regulations, good skills in communication and should be be able to handle situations in a professional manner hence should acquire good leadership skills(Hegney et al. 2013).

3.5) In order to develop better skillsets required for the role of a nurse manager, training can be undertaken in the Australian school of nursing and other such institutes under the state or local government. To emerge as an efficient nurse manager the future goals should consists of being an inspirational leader as well as being head strong in taking decisions in complex situations. The emotional drive of the staff needs to be understood and care should be taken to pacify the fears behind people’s reaction. Focus has to be given to recognise every member of the unit in order to get the best out of them.

References:

Health.qld.gov.au 2018. Records Management for Museums and Galleries. [online] Available at: [Accessed 1 Jun. 2018].

Crnbc.ca. 2018.Legislation relevant to Nurse’s Practice [online] Available at:  [Accessed 1 Jun. 2018].

El Haddad, M., Moxham, L. and Broadbent, M., 2013. Graduate registered nurse practice readiness in the Australian context: an issue worthy of discussion. Collegian, 20(4), pp.233-238.

Ellingson, K., Haas, J.P., Aiello, A.E., Kusek, L., Maragakis, L.L., Olmsted, R.N., Perencevich, E., Polgreen, P.M., Schweizer, M.L., Trexler, P. and VanAmringe, M., 2014. Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control & Hospital Epidemiology, 35(8), pp.937-960.

Gould, D.J., Creedon, S., Jeanes, A., Drey, N.S., Chudleigh, J. and Moralejo, D., 2017. Impact of observing hand hygiene in practice and research: a methodological reconsideration. Journal of Hospital Infection, 95(2), pp.169-174.

Hegney, D.G., Patterson, E., Eley, D.S., Mahomed, R. and Young, J., 2013. The feasibility, acceptability and sustainability of nurse?led chronic disease management in Australian general practice: The perspectives of key stakeholders. International Journal of Nursing Practice, 19(1), pp.54-59.

Hendricks, J.M. and Cope, V.C., 2013. Generational diversity: what nurse managers need to know. Journal of advanced nursing, 69(3), pp.717-725.

Luangasanatip, N., Hongsuwan, M., Limmathurotsakul, D., Lubell, Y., Lee, A.S., Harbarth, S., Day, N.P., Graves, N. and Cooper, B.S., 2015. Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. bmj, 351, p.h3728.

Nardi, D.A. and Gyurko, C.C., 2013. The global nursing faculty shortage: Status and solutions for change. Journal of Nursing Scholarship, 45(3), pp.317-326.

Powell, I., 2013. Can you see me? Experiences of nurses working night shift in Australian regional hospitals: a qualitative case study. Journal of advanced nursing, 69(10), pp.2172-2184.

Scully, N.J., 2015. Leadership in nursing: The importance of recognising inherent values and attributes to secure a positive future for the profession. Collegian, 22(4), pp.439-444.

Staats, B.R., Dai, H., Hofmann, D. and Milkman, K.L., 2016. Motivating process compliance through individual electronic monitoring: An empirical examination of hand hygiene in healthcare. Management Science, 63(5), pp.1563-1585.