M.Cur. (Intensive Care Nursing) / The nurse working in an intensive care unit is legally accountable for complete and accurate record-keeping. Record-keeping is especially important during a crisis incident as the sequential management or treatment depends on what happened before and during the crisis incident. Before she can be held accountable for complete and accurate record-keeping, the nurse must have the necessary abilities (knowledge, skills and values) . She will have to accept the responsibility and legally she will receive the authority for it. Complete and accurate record-keeping helps to maintain, improve and restore the critical patient's health. In this way the nurse working in an intensive care unit facilitates the patient's aim for wholeness and at the same time achieves her own aim for' quality nursing. The purpose of this research is accurate nursing records are kept intensive care unit. A contextual-descriptive research design, including a survey method and retrospective auditing were used to determine the completeness and accuracy of record-keeping by nurses during a crisis incident. Auditing was done on the basis of three structured control lists. The results showed that the graphic-symbolic report was more complete and accurate with regard to the patients' particulars and graphic accuracy. The results also showed that there is a great variance in the knowledge and skills of the nurses working in the intensive care unit, regarding record-keeping. Recommendations evolving from this study are: The purpose and use of the records should be clarified. The record system must be revised. Temporary staff must be accompanied on day duty by permanent staff members before they start working night duty. The allocation of the staff must be revised. A policy for record-keeping must be established. In-service training for expanding knowledge regarding record- keeping must be initiated. The purpose and the use of record-keeping must be included in the orientation program. Records must be evaluated to identify shortcomings.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:uj/uj:10814 |
| Date | 23 April 2014 |
| Creators | Marais, Sanet |
| Source Sets | South African National ETD Portal |
| Detected Language | English |
| Type | Thesis |
| Rights | University of Johannesburg |
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