Category: Human Physiology

Phlebotomy is an invasive field that is used for the collection of blood used for testing or donation. This is done by an insertion of a needle to a vein which may be dangerous in the hands of phlebotomist without proper training. Because safety is a priority of many phlebotomist, we’re seeking ways that we can enhance safety for both the medical worker and the patient when drawing out this bodily fluid from the patient. To minimize the risk of infection and injury, we utilize safety engineered devices that in return aid us in preventing infection and trauma. ‘Such devices reduce exposure to blood and injuries’ (NCBI 1). I propose that in order to help aid phlebotomist in training from injuring people, we incorporate safety engineered devices for assistance alongside proper training for phlebotomist and education consistent with all phlebotomist.

How can we minimize the chance of trauma in phlebotomy whether to the patient or to the phlebotomist in a way that allows the phlebotomist to draw blood without any problems? There is a lot of room for error in the healthcare field and what can go wrong will go wrong. Therefore, we need safety precautions in place and safety engineered devices can help. Injuries and risk of infection can affect medical workers because they can become contaminated with any disease that patients carry. Patients are also at risk because of wounding and infection. (NCBI 3). Blood borne infections can occur from the needlestick and cannot always be prevented by gowns or gloves. Any contact with patients is immediately a risk of contamination. Treating every patient as if they are infectious is important because you never know what people are carrying. Safety engineered devices can be used and can incorporate universal precautions, avoidance of bodily fluids with protection such as gloves, googles or face shields.

“Safety engineered devices are available on the market, such devices reduce exposure to blood and injuries, However the use of such devices should accompany other infection prevention and control practices and training in their us” (Common). I believe safety engineered devices will aid in the reduction of injuries because technology can be used to our aid along with proper training and they can lower phlebotomy related injuries due to errors by phlebotomist. Similar to how personal protective equipment is used to avoid bacteria or viruses, safety engineered devices are starting to be used in phlebotomy, this includes syringes that can be slid closed with sheaths or retractable needle systems. These devices are specifically engineered to prevent damage to the phlebotomist or to the patient, acting as another barrier on top of the personal protective equipment that already protects the primary care worker from airborne and bloodborne transmissions. This affects primary care workers and clinics. Because they are specifically designed to prevent wounds in the medical environment, safety engineered devices can be expensive and may not be available to all clinics such as those who cannot afford them. However, clinics are not required to utilize safety engineered devices if they do not feel the need to. “The document goes on to allow for the following considerations in adoption of a safety devices: No one medical device is considered appropriate or effective for all circumstances. Employers must select devices that, based on reasonable judgment: will not jeopardize patient or employee safety or be medically inadvisable; and will make an exposure incident involving a contaminated sharp less likely to occur.” (Total Medical).

Safety engineered devices can only do so much in the health care environment. Phlebotomists are responsible for planning ahead, using appropriate locations to draw blood, quality control, appropriate training, cooperation with patients. (NCBI 1) There is a lot

of human errors such as patient misidentification, in the phlebotomy pathway we learned to take the first name and date of birth of the patient to confirm that is the patient we are supposed to be working on. We can use the skills in our pathway to minimize errors. Not only that but in phlebotomy we learn of proper ways to draw blood from patients. We learn what not to do when drawing out blood, which is helpful because we can avoid these wrong actions when we’re actually drawing out blood from a patient and not from a fake arm with fake blood. As a matter of fact, we utilize safety-engineered devices in our phlebotomy class, ranging from a retractable sharp to a sharp disposable container. We are well aware of their benefits because without them we’d lose one of the many layers of protection that we have in the health care field.

Engineered safety devices have a lot of potential in the health care industry they are capable of minimizing errors where errors can happen. The health care field is not immune to human errors, therefore with safety-engineered devices errors can be minimized because they’re a barrier that protects both the patient and the medical worker.

Works Cited:

1. Best Practices in Phlebotomy. Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, 1 Jan. 1970, www.ncbi.nlm.nih.gov/books/NBK138665/;
2. 2 How To Draw Blood Like A Pro: Step-By-Step Guide. Nurse.org, nurse.org/articles/how-nurses-professionally-draw-blood/;
3. Best Practice in Phlebotomy and Blood Collection. Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, www.ncbi.nlm.nih.gov/books/NBK138496/;
4. Common Phlebotomy Errors and How to Avoid Them. Phlebotomy Career Guide & Outlook, www.phlebotomyguide.org/common-phlebotomy-errors-avoid/.

The biggest reason for keeping and maintain records is to ensure that the client will get continuing care as accurate as possible. Record keeping is actual communication between health care workers and clients, where it includes care planning, quality assurance of care for clients, legal documents. Record keeping is very important for care workers as they are updated every day and any changes are passed from shift to shift and when they finish they work. Those records must be kept from reach of the different clients and their families, friends and actually anyone who is not responsible for clients (Residents) wellbeing from physical to emotional side.

Record keeping of the care assistant are usually made by Nurses with admission of the client (Patient) this is already made in front as they usually have forms ready to go which are premade for care assistant staff. Record keeping of nurses and care assistants is as well proof that the client (patient) did get appropriate care which he/she needs as well as they are proof in legal cases where they are used as an evidence and there for they must be as much accurate as they can.

The records should have relevant information’s such as relevant clinical findings, where doctors can diagnose and continue with treatment of the client where there is also decision made and relevant action appropriate to clinical findings and who is actually making the decision and who is agreeing with it as well, which should be signed with both parties. Another is the information given to the client and any drugs which are prescribed to the client (patient) or other findings and investigations which will help the client with his/hers recovery or treatment and of course who is making the record and when and what time and date it was last updated as for future treatments, consultations or tests necessary for future treatments and as well clients progress, findings on examinations (tests), monitoring and follow up arrangements with client where the details of the client contacts are included in the records for future consultations in person or on phone, where all of them must be recorded, even if the client refuse future consultations where the reason must be recorded as well. Those records might be anything from Text message or emails up to written notes.

The records of the health care assistant are different as they don’t possess that many information’s as medical or nursing records and are differently orientated. As example the records in the nursing home are orientated more on caring part of the client and not his/hers diagnosis or treatment.

There are stating the name of the client, the date, time and year when he/she was first time admitted to the facility or nursing home. If the client have the room then the room number is included in those records, as to know where the client will spend his night. Other information’s such as if the person needs assistance to go to the bed or him/her-self are independent, if they have the call bell, which will call care assistant in needs, or if they are using a floor alarm which will inform the care assistant if they are out of the bed. Those are used in cases of high risk falls and if the person is confused to the point where he/she don’t know where they are and need some insurance that they are in the right place. The next might be the personal hygiene as there is some the cases where the person might need assistance with daily washing, or bath or shower or mouth hygiene which the care assistant is able to provide, where of course the dignity and respect Must take a place at all times. As it goes with hygiene the next Colom might be the transfer where it is depending on the clients condition, as he/she might be independent or using the wheel chair or they are bed bound. The transfer might be non or with assistance of one or two or the hoist where the care assistants will use them in appropriate and right way as they have been trained and make sure that they won’t do any harm to the client or them-self’s by doing so. Next part is about the mobility of the clients as not all can move freely by themselves there might use the walking aid or need assistance by one of the carers or by only supervised or they might use the wheel chair for transfer longer distances. This might not look like it but many clients (patients, residents) might use wheel chairs especially elderly or clients with disability. In some of the records there might be Colum for the sleep patterns as not all of the clients might sleep the same and that goes especially for the clients with mental dysfunctions, or disability’s. As the rest it might be accordance with the room of the clients. The example might be that the pillow cases have been changed, where it goes for the linens as well, or the duvet covers, or if the client have clean clothes on him/her or if they are properly groomed, etc. next it usually is the bladder and bowel movement as not all clients are independent and need assistance with toileting but even so with established trust between the client and care taker the carer might also ask the client if there was any movement where those are most likely monitored ourly.

Where confidentiality must be in place as the client’s privacy must be protected all the time. All clients information such as written, any kind of records or only kept in the memory of care worker is confidential and must stay this way until the client will agree otherwise.

This Includes:

• Any diagnosis and treatment;
• Pictures, photographs, video and audio of the client;
• Who is the patient’s doctor, what department/s they have been attending and when;
• Or anything what can actually identify client directly or indirectly.

Confidentiality is very important as it establishes the trust between the client and care worker and can actually talk about the worries and problems which sometimes they might think that they are embarrassing or trivial in the point of view. If the confidentiality is broken the clients (Patients) might even stop looking for medical or professional help and it might/will affect their health or mental wellbeing. That is the reason why confidentiality has an enormous impact on security, freedom, self-respect, and freedom for clients.

As it is all collected data (information) about the client (patient) in confidence must stay confidential and can be used only in the sense which they were originally collected unless there is a legitimate legal reason for disclosure. The information is staying confidential even after the death of the client (patient). As it is the staff is as well only on a need-to-know basis with the client’s information as to complete the purpose of their work only.

As for clients, the care worker should always shove dignity and respect for the client as those are the basics of first contact and communication between them, the care worker should never discriminate the client (Patient) directly or indirectly against their gender, family status, age, disability, sexual orientation, religion, race, color, nationality or ethics or etc… As it happens before in Ireland and there are many cases of discrimination, where the prohibition might be in place in some cases and the client is now protected by law. The care worker should not as well take any money or other different things as payment as it might or will affect the professional judgment of the carer and be expecting even more in the future as it might affect the relationship with the client. This might even go as far as theft or neglect.

If we look at it from our point of view the carer’s records are not the same as the records of the nurses or medical records of any kind and so it is only on must to know basis. Even so, those documents are protected by confidentiality, and not all personal can access them as they will for their own information knowledge or to pass the information to a third party. The confidentiality of that information is protected by law and that is the reason why they should not be breached by any circumstances at any time even if there is a requirement for them at the present. As for the phlebotomist, those information’s are not even on a must-know basis, where when their ask for them there might be an ethical dilemma or issue which can contradict the studies of the care assistants, and then the care assistant should go back to the basics and ask for the contents of the client if he/she is allowed to provide those information’s and by which occasion and if they are necessary for the particular procedure required on this occasion, as well as to ask for written consent of the client to make sure that they are protected if any confidential information is lost or given to another party.

During my observation in phlebotomy section of pathology lab, I learned how the samples were collected from the patients.

According to my ease I can divide the whole procedure into following parts:

• Making the Patient Comfortable: The first step in performing a successful venipuncture is to make the patient comfortable. For this purpose make the patient sit down in the chair and talk to them in order to reduce the possible stress that they are feeling;
• Locating the Veins: In this step a tourniquet in used to constrict the veins and build pressure in them. Locating the veins is a tricky thing as you have to feel the right vein to draw blood by touching and pressing the veins. The diameter of the vein is estimated and then we finally decide the most appropriate vein to draw blood from;
• Disinfecting the area: Spirit swabs are used to disinfect the area from where blood is to be drawn. The area is thoroughly cleaned to prevent any infection or harmful bacteria from going inside the skin;
• Drawing Blood: Finally a syringe is used to pierce into the skin and slowly the blood is drawn out. The quantity of the blood drawn depends upon the tests that are to be done. This blood is stored in vacutainers. These vacutainers are then marked with a number and date on them.

Following are the type of vacutainers used in Anmol:

• Red Top: This vacutainer is used to collect blood on which biochemical tests are to be performed. For example LFT, RFT, LDH, Lipid profile, Calcium, etc;
• Grey Top: This vacutainer contains Sodium Fluoride that inhibits RBC’s from consuming blood sugar. The blood stored in this vacutainer is used to perform Blood glucose level tests;
• Purple Top: The blood stored in these vacutainers is used for performing tests like CBC (Complete Blood Count).

Hematology: In this section, tests like CBC (Complete Blood Count) and ESR (Erythrocyte sedimentation rate) are performed. The Analyzer used in this section is Sysmex KX-21. The vacutainers are put on rollers that keep on mixing the blood in order to prevent any type of clotting.

Following tests are performed here:

• WBS’s- No of White Blood cells (Per microliter of blood);
• RBC’s- No of Red blood cells (Per microliter of blood);
• HB- Hemoglobin (g/dl);
• HCT- Hematocrit blood test;
• MCV- Mean Corpuscular Volume;
• MCH- Mean Corpuscular Hemoglobin;
• MCHC- mean corpuscular hemoglobin concentration;
• PLT- Platelets;
• LYM- Lymphocytes.

A phlebotomist is a valued member of a health care team and plays an important role. They are responsible for collecting, processing, and transporting blood specimens to the laboratory. A phlebotomist is skilled in the art of venipuncture which the puncture of a vein with the intention of drawing blood is carried out. A phlebotomist obtains blood samples, there are 3 ways blood can be taken by a phlebotomist which are venepuncture, drawing blood from a vein, capillary puncture, obtaining blood from the capillary bed, and arterial puncture which is drawing blood from an artery. The most common collections are venipuncture which is from the vein and dermal puncture which is where a lancet is used to puncture the skin and draw blood from the capillary. A phlebotomist will take blood samples at a skill level that requires blood to be collected in appropriate testing tubes and then the tubes are sent to a laboratory for testing. There are three main veins to obtain blood and are the median cubital vein, this vein lies over the cubital fossa and serves as an anastomosis between the cephalic and basilic veins, the cephalic vein, shown in both forearm and arm, can be followed proximally where it empties into the axillary vein and lastly the basilic vein, it divides to join the brachial vein.

A phlebotomist should review the collection order and priority, being prepared will establish confidence. There is a certain order of drawing that must be followed. A phlebotomist will always explain the procedure to the patient and must remember the patients’ rights before any procedure can begin, after explaining the procedure to the patient a phlebotomist must remember that the patient has the right to refuse. Patients have been known to refuse blood to be drawn even if the sample is ordered by a physician. Even after explaining to a patient that the sample is needed for results regarding treatment the patient refuses this must be noted and reported to the appropriate person. A phlebotomist must never ignore the patient’s refusal because this can lead to a lawsuit for battery if a patient is intentionally touching a patient without consent. There are a few ways consent can be given for example nonverbal consent is where a patient might offer you their arm once a procedure has been explained and another is verbal, his is when a patient clearly states their consent by communication. A phlebotomist must be careful not to harm a patient, they must take blood correctly so that it can be used for testing, they must label the samples correctly, store the blood taken properly and deliver samples to the lab.

A phlebotomist must learn and follow all safety regulations, these are very important especially when dealing with body fluids and potentially infectious samples. Data shows that there are between 900 and 1000 needlestick injuries in Ireland every year with almost half being nurses but most are not reported due to the stigma which means that they could be at risk from fatal infections.

The knowledge, skills, and attitudes will now be discussed in detail in relation to what a phlebotomist is required to have in order to carry out his or her job in a competent professional manner. As a phlebotomist will be working on human patients in real-time, there is no room for error. Knowledge of human anatomy, first aid, and interpersonal skills are required. phlebotomists draw blood from patients for testing, research, transfusions, and blood donations. They also label the blood for processing, enter information into a computer database and assemble and maintain all relevant medical equipment needed. Hand hygiene is very important and is the first step to infection control. A few examples of hand hygiene are, hands should be washed before putting on gloves, and again when the gloves have been removed, hands should be washed properly using the appropriate handwashing technique and again in between patient contacts. Gloves do not replace hand washing.

Labeling and entering information into a database might seem like a simple task at first, but the importance of this job cannot be overstated. If a person taking blood in any way mislabels test tubes or enters incorrect results into a database this could have a detrimental effect on the result and could put the patient’s life in jeopardy. As has been shown recently in Ireland, there were some false positive cervical smear test results. Knowledge in a system of correct labeling and the correct recording of information in a database is as important as the art or skill required to obtain the patients’ blood.

As it is the phlebotomist’s job to assemble and maintain the medical equipment needed to draw blood, knowledge of the maintenance and functionality of these instruments would be an advantage. Sharps bins are provided and need to be used correctly, they are used for used syringes, lancets, and needles. These buns should only be filled to the indicated line and, closed and locked, and then your name and date are written on the label. Phlebotomists will always have to explain the procedure to the patients, get consent, and reassure patients who might be of a nervous disposition. A phlebotomist needs certain skill sets which fall into two categories called hard and soft skills. The hard skills are the skills required to physically carry out the job at hand. This is when the practical aspects of the training course and work experience become essential. The soft skills are compassion and empathy, these are required for an anxious patient so you can put yourself in their position and imagine they would feel.

Overall there are five main skills for a phlebotomist to acquire and they are as follows, attention to detail, communication, data entry, dexterity, and empathy. When dealing with the public especially when carrying out these procedures interpersonal communication is an important soft skill to have. Clients when attending their first procedure may be anxious, a caring and understanding phlebotomist who can empathize with the patient will try to make the patient as comfortable as possible. Communication with the patient and maintaining confidentiality are also very important. In relation to interpersonal skills the importance of listening to a patient can be beneficial. If a patient does not feel listened to this can increase their anxiety and can make them feel like the procedure is being rushed. Personal attributes such as accuracy, attention to detail, collaboration, continual professional development, dexterity are a few skills that can be learned and put to great use when working as a phlebotomist.

Once a person becomes a phlebotomist, this is not the end of the training, upskilling and retraining are important as they keep the phlebotomist up to date on any changes and standards that may occur. When it comes to phlebotomy, dexterity is one of the most important physical attributes to have when taking a blood sample. Any misdirected syringes could damage a vein or hit an artery. A person with bad dexterity could make the patient nervous. A hospital can be very busy at times, a phlebotomist must balance efficiency along with due care and attention to the patient, greeting and identifying the patient and having a friendly conversation is the first step. A phlebotomist’s image is very important. Behaviour, personal appearance, and tone of voice all contribute to this image. Acting in a professional and courteous manner keeps the patient at ease and gives the patient in the phlebotomist. In relation to general appearance, good hygiene is recommended.

Always respect a patient’s personal space even when greeting them on arrival and carrying out the procedure. Body posture is equally important and always make eye contact when explaining a procedure. A calming and reassuring voice can put the patient at ease. Blood samples are taken to figure out what’s wrong with a patient, to make sure treatment is working, and to develop the right treatment or choose the right drugs. Working as a phlebotomist has certain risks, blood can transmit dangerous viruses, bacteria, and airborne contaminants. Needle sticks are common injuries among phlebotomists and those who start intravenous infusions. Between 600,000 to 800,000 people stick themselves with needles each year; around half don’t report their injury, the director of the National Institute for Occupational Safety and Health reported in 2000.

Knowing what to do when a needle stick injury occurs is vital. Squeeze the wound to encourage it to bleed, hold the wound under running warm water, dry the wound and cover it with a plaster and seek urgent medical advice. Do not suck the wound or scrub it while washing it. phlebotomists can also have a latex allergy which can cause respiratory problems, rashes, wheezing, and shortness of breath. A Phlebotomist can also encounter difficult patients; they can be intoxicated and combative, so they need to be careful when taking blood to protect themselves, the patient, and the people around them.

So, to conclude a phlebotomist has a very important job, they are a valued member of the medical team. Phlebotomy is an invasive procedure; patients can suffer permanent disabling injuries if they do not know what they are doing. You need to focus and know exactly what you are doing. A phlebotomist’s responsibilities include safeguarding the health and wellbeing of the public, taking blood in a safe manner, labeling the vials with patient’s names and dates of birth, and transporting the vials safely to a laboratory for testing. A phlebotomist will need to have a friendly and courteous manner, they will need to sympathize with anxious or nervous patients, present themselves in a professional manner and be confident in their job. Honesty is an important skill to have when working as a phlebotomist, saying that the procedure will not hurt is not being honest with your patient because every patient is different. Good dexterity is needed when working with needles, it is very easy to hurt a patient when taking blood. Blood needs to be drawn quickly and efficiently.

A phlebotomist must know exactly where the vein is and be careful not to hit an artery or cause harm. Infection control is one of the most important skills for a phlebotomist to have in order to stop the spread of infectious diseases. Hand washing must be done before and after patient contact. Work areas must always be kept clean and sharps must be handled with caution and disposed of in a safe manner in the sharp’s container.

The three main points needed to become a successful phlebotomist have been discussed at length. The knowledge and skills needed for this evasive procedure are of paramount importance in conducting a clean and safe venipuncture. When you combine the knowledge and skills that you have, you will in time become a competent and professional Phlebotomist. As already stated, the knowledge and skills obtained must be continuously worked on over the years. It is not good enough to just complete a phlebotomist course and think that this is the end, in fact, this is only the beginning of a long road of training and upskilling that you will indeed yourself be able to pass on to the next generation of young phlebotomists. You will learn many things through books and courses but the knowledge you obtain from seasoned professionals will be very important as you progress through your chosen profession. While the knowledge you obtain from coursework can be obtained by anyone, the actual soft skills to learn can be personal. Not everyone interacts with people in the same way. There are extraverted people and introverted people which have different personalities, and these people interact with the public in different ways. If you are an extrovert, you will probably find it easier to interact with people and therefore make the patient comfortable. This is not to say that an introverted person cannot become a good phlebotomist, in fact, there is a possibility that with the correct training and working with the right people, a person could over time become outgoing and could benefit from it.

According to The State Archives and Records Authority of New South Wales (NSW State Archives and Records 2008), information is the primary organizational asset needed now and in the future, and good record-keeping can help people find the information they need. It can also help to promote information sharing and collaboration. If the information is accessible and trustworthy, it can be used to make more informed decisions and take appropriate action. Since health care is considered professional, caregivers need to document their work as they are completed, so as a phlebotomist. In medical care, record-keeping is important to both patients and nursing staff. There are many reasons for keeping medical records in health care, but two of them are more prominent than others: “Prepare a complete record of patient/customer journeys through the service; Provide ongoing care to patients/customers within and between services”. (Royal College of Nursing 2016) Record keeping is a critical and ethical responsibility for health care professionals. In this paper, the writer will critically discuss record-keeping, detail what is record keeping, the important value of the nursing records,s and the principles of record keeping.

Responsibility and skills a phlebotomist need

Some of the main responsibilities and skills required by blood collectors are as follows: Blood Collection—a phlebotomist will be the person who draws blood from the patient and marks the blood bottle and be responsible for bringing all blood samples to the local laboratory for testing. (phlebotomy training information 2017) Communication skill—Phlebologists must maintain a professional attitude with other health professionals and patients. For some patients who are afraid of blood collection, a friendly attitude, compassion, and reasonable use of conversation tactics can help patients relax and reduce tension. (Chron 2019) Infection control—various diseases, such as hepatitis, HIV, etc. can be transmitted through blood. Blood drawers must strictly follow the safety requirements to protect themselves and their patients. (phlebotomy scout 2019) Housekeeping—according to Chron (2019) that the phlebotomist is responsible for keeping their supplies and equipment in good condition, keep supplies in stock and organize them for easy access; Keeping the blood trays fully equipped and ready in case of a doctor orders a draw of blood elsewhere at the hospital. Record-Keeping—phlebotomists help keep patients and lab records up to date. They must mark the sample properly with the patient’s full name, date of birth and I.D. number, and other information such as the time and date of collection; They usually also need to enter information about blood samples and tests into the digital data entry system. (Chron 2019) Safety—the phlebotomist must be aware of needle injuries to avoid harm to themselves or their patients and to prevent the spread of blood-borne diseases. They need to keep hand hygiene and follow a sterile procedure. (Chron 2019)

Record and record-keeping

What is Record? In the medical field, nursing records are permanent written communication that records information related to a client’s health care management. It is the original written record of the observation and implementation of nursing measures by health professionals. Nursing records are legal documents and have legal effects. (Jasleenkaur B. 2015) Record keeping refers to maintaining a person’s activity history, as a financial transaction, by entering data in a ledger or journal, putting documents into files, and so on. In the medical field, record keeping is the act of organizing and recording information related to patient care. (Dictionary.com 2019) A good patient record includes detailed record details about patient care and the patient’s response to the care. (study.com 2019) Different records retention methods were used in the health care environment. Some workplaces use handwriting records, some workplaces use computer-based systems, and many workplaces use both. According to the Nursing and Midwifery Board of Ireland (NMBI), the client records that an individual nurse, midwifery, or phlebotomist keep within a legal, ethical and professional framework should be clear, accurate, honest, and current. It means that they should be written as much as possible to the actual time of the event they describe.

The important value of nursing records is reflected in the following aspects:

• Communication – The medical staff can understand the patient’s needs and the treatment and care process by reading to achieve mutual communication;
• Assessing patients – Information obtained from records such as admission assessments, hospitalization assessments, etc. can help identify patient needs, identify patient health issues, and develop targeted care plans;
• Investigation and research – Complete nursing records are important materials for nursing research and have reference value for retrospective research;
• Teaching Resources – A standard, complete nursing record allows health professionals to see the specific application of theory in practice and is the best material for teaching;
• Assessment – The nursing record reflects the quality, academic and technical level of a hospital’s nursing service to a certain extent. It is an important information material for hospital nursing management, and also a reference for hospital-grade assessment and nursing staff assessment;
• Legal Basis – The nursing record is a legal document and is legally recognized evidence.

Legal issues in record-keeping

The content and processing of clinical records are strictly regulated by law, not only because they are the basis of high-quality patient care, but also because they are increasingly used in courts and are an important source of confidential personal information. (NCBI 2016) According to the Royal College of Nursing (2016), the UK health department has done two things about the legal aspects of keeping health record-keeping: Individuals working for health care organizations are responsible for what they write. Personally writing anything about their work as a health care worker becomes a public record. So you have to pay attention to what you write. For example, not only do you need to formally explain your records when a patient complains, but the patient can also request a copy of what you write through the Data Protection Act. (Royal College of Nursing 2016) There is also the question of whether health care assistants have the right to make the record and write down the care they provided to patients. In fact, as long as registered nurses represent this responsibility, health care assistants are qualified to carry out the activity and its documentation. In some countries, such as the UK, data security and data sharing laws can be very strict. The Royal College of Nursing has produced guidance on delegating record-keeping and countersigning records.

Principles of Record-keeping

Patient records are permanent records of care provided by health professionals. Failure to fully record important patient information on the medical record is the negligence of the caregivers. There are general principles that health professionals and authorized care assistants must follow to ensure the records do their job, whether it is handwriting or electronic system input, can be summarized by stating that anything you write or enter must be functional, accurate, complete, current organized and confidential. (RCN 2016) These principles are explained in detail as follows: Functional means that record information about the customer and their care must be valid. It is a true portrayal of a series of nursing activities carried out by health professionals to patients. It records the whole process of a patient’s treatment, nursing care and reflects the evolution of the patient’s condition. Accuracy means that customer or patient records must be reliable. In order to give confidence to health team members, information must be accurate. (Jasleenkaur B. 2015) Complete means that the information in the record entry or report should be complete, containing concise and comprehensive information about patient’s care, or any event that occurs within the jurisdiction of the administrator. Current means that any recorded incidents should be updated as soon as possible; provide up-to-date information on patient care and status. Delays in recording or reporting can lead to serious omissions. (Lydia N 2018) Organization means that health professionals convey information in a logical format or sequence. When members of the health team are arranged in the order in which they appear, they will have a better understanding of the information. (Jasleenkaur B. 2015) Confidentiality is a principle that cannot be ignored. According to The Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives (2014), the caregivers are legally and ethically obligated to keep information about the client’s illness and treatments confidential. If these principles being followed properly, the contribution to record-keeping will be valuable.

There are some more things that need to pay attention to when recording: the caregiver’s record-keeping quality should ensure that continuous care for patients is always supported, and any jargon, witticisms, or derogatory words should not appear in the record. (NMBI 2014) In case the patient might want a copy of the record, the content of the record should be accurate and understandable; Focus on facts, not speculation; Abbreviations cannot be used on documentation to transfer, discharge, or external referral letters. (RCN 2016) Delete or change is scored by a single line followed by the signature (plus name in capitals) and counter-signature, if appropriate; date and time of correct entry, no scraping, sticking or painting methods shall be used to cover up or remove the original handwriting. (RCN 2016) While doing corrections, don’t mark or change anything written by someone else, or change anything that wrote before. Never write any patient or colleague about an insult or derogatory. (Health Service Executive 2019) Always follow the principles described in the written communication section and keep in mind to report to the responsible registered nursing staff when finding something important in working with patients. Write it into the patient/customer’s record. Always report first and then record.

According to the Royal College of Nursing (2016), health services need to maintain good patient care written record for three main reasons: First, continuous and safe care and treatment can be carried out no matter which employee is on duty; Second, to record the care that has been given to the patient/client; Third, when the patient/client complains about the care they receive, make sure that an accurate record is used as “evidence”. Since the level of actual participation in written medical records varies from workplace to workplace, it is important to understand the expectations in the workplace and ensure compliance with the rules.

Nursing records should be written on the basis of facts, correctness, and consistency, be as close as possible to the time when the care provided or events occur; write simply and clearly, if typing in a computer, try to avoid mistakes, if written by hand, write clarity, when specific events and situations occur, insert dates and times as accurately as possible to invalidate and express personal opinions. Avoid making any judgment or personal insults, write the observation into the report. Remember, as part of the health care team, it’s the health professional’s responsibility to ensure that everything written about patients/clients is confidential and that no one is authorized to access them. This is considered an important issue of confidentiality.

Disadvantages of poor record-keeping

Incomplete and untimely records: Health professionals are busy completing various treatments and daily nursing work, the changes of patients illnesses and nursing activities can not be recorded in time, the medical records are often retrospectively recorded before the end of the work, this resulting in the phenomenon that the medical records are omitted, not timely or even not recorded, which distorts the value of nursing records. When medical disputes occur, no favorable evidence can be provided. Phlebotomists need to complete high-intensity collection work in a short time, with a heavy task and a compact working rhythm. It is one of the important reasons why blood collectors can’t input and submit the information of specimens correctly when they are busy with their work. Otherwise, if the blood collector has not been trained in place, and the relevant knowledge has not been updated in time, it resulting in inaccurate or incomplete information about the specimen. Defects in the authenticity of nursing records: In order to improve the surface quality of the medical records and to cope with the examination, the unimplemented nursing measures are fictitious in the nursing record. For example, oral care for patients three times a day in the records, but only once in practice. Such substantive issues require good supervision by clinical managers. For phlebotomists, incorrect identification of specimens resulting in unnecessary repetition of tests or other investigations. This misuses medical professionals and prolongs the length of hospitalization. More serious, it may lead to an incident. (hcpro.com 2019) According to NCBI (2016), incomplete documentation in patient’s clinical records may lead to increased legal costs, inaccurate statistical databases, and also lead to poor patient care by other medical team members who take over. That’s why every organization should ensure accurate and complete clinical records.

Conclusion

A recording is an important part of nursing practice and has clinical and legal significance. Good quality records are associated with improved patient care, and poor documentation is considered to be the cause of poor quality care. Regardless of the form of medical records, good clinical record preservation should ensure the continuity of care and strengthen communication between different health professionals. Maintaining high-quality records and reports has direct and long-term benefits for all health care professionals. A good medical record can reduce the time of repeated blood tests, avoid giving an inaccurate diagnosis or inappropriate prescription treatment, and benefit patients greatly. In addition, good clinical record keeping can help to make decisions for individual patients and save time for those who need it most. Finally, poor clinical records can have a profound impact on patients’ lifelong health. Therefore, never forget the importance of the responsibility to share information and the obligation to protect patient confidentiality.

References

1. Future Proof – Protecting our digital future. 2008. Why is good recordkeeping important?. [ONLINE] Available at https://futureproof.records.nsw.gov.au/wp-content/uploads/2008/06/Why- is-good-recordkeeping-important1.pdf. [Accessed 26 February 2019].
2. Chron. 2019. Role of Phlebotomist. [ONLINE] Available at https://work.chron.com/role-phlebotomist-15696.html. [Accessed 26 February 2019].
3. Phlebotomy training information. 2017. Introduction to phlebotomy. [ONLINE] Available at
4. http://phlebotomy-training-information.com/free-downloads/Introduction-to-phlebotomy.pdf [Accessed 8 March 2019].
5. PhlebotomyScout. 2019. Phlebotomist Job Description. All You Need to Know. [ONLINE] Available at http://phlebotomyscout.com/phlebotomist-job-description/. [Accessed 26 February 2019].
6. Jasleenkaur B. 2015. Nursing records & reports. [ONLINE] Available at: https://www.slideshare.net/jasleenbrar03/nursing-records-reports. [Accessed 6 April 2019].
7. Dictionary.com. 2019. Recordkeeping. [ONLINE] Available at: https://www.dictionary.com/browse/record-keeping. [Accessed 26 February 2019].
8. Rebecca G. 2019. Principles of Recording in Nursing. [ONLINE] Available at https://study.com/academy/lesson/principles-of-recording-in-nursing.html. [Accessed 6 April 2019].
9. Royal College of Nursing. 2019. Record keeping. [ONLINE] Available at https://rcni.com/hosted-content/rcn/first-steps/record-keeping. [Accessed 26 February 2019].
10. NCBI. 2019. How to keep good clinical records. [ONLINE] Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297955/. [Accessed 26 February 2019].
11. Health Service Executive. 2019. Health Service Executive Standards and Recommended Practices for Healthcare Records Management. [ONLINE] Available at https://www.hse.ie/eng/about/who/qid/quality-and-patient-safety-documents/v3.pdf. [Accessed 26 February 2019].
12. Lydia, N. 2018. Record Keeping and Documentation. [Online]. Available from: https://www.ausmed.com/cpd/articles/record-keeping-documentation [Accessed 6 April 2019].

We can’t deny the importance of sleep because it’s a necessity to stay healthy. All of us need at least an acceptable amount of sleep so that we can feel better and wake up with a fresh, clear mind. However, if you don’t get good sleep, you feel annoyed and unfocused throughout the day and you become stressed out. This has a negative influence on both our health and well-being, as well as our lifestyle. This is why you should get at least 7 hours of sleep each night, 8 hours would be more desirable. Anything below 7 hours would negatively impact you in the long run.

To live a healthy lifestyle, good sleep is absolutely essential, and without good sleep, health problems such as Alzheimer’s or dementia slowly start to develop as you grow older. Surely, you wouldn’t want this to happen. Therefore, you should pay more attention to your quality of sleep and ask yourselves: ‘Am I getting enough?’.

Sleep is an important factor that determines our overall health. It improves how your body functions and is necessary for having a healthy lifestyle. Moreover, there are many more benefits that you can have with the right amount of sleep.

One benefit is that good sleep improves your memory and reaction times. This is due to the fact that if you have a good amount of sleep, you’ll feel more focused, and this will help you to concentrate on your work, therefore improving your memory and work performance. When you have a fresh mind, you’re more alert and can react to things faster, which will aid your driving performance and your sports performance. According to researchers, it’s discovered that you also learn while you sleep.

Another benefit is that good sleep can boost your creativity, as creativity comes from being stress-free and relaxed. This benefit can only be gained if you sleep well enough. 7-8 hours of sleep is necessary for each person, as it gives you the feeling of relaxation. When both your body and mind are relaxed, you’ll think better thoughts throughout the day, therefore you’ll be innovative and have more original thoughts and ideas. With the right amount of sleep, creativity will come to you naturally.

A lack of sleep has been shown to have a strong correlation with health issues. Many people complain about their health problems, and the main cause is not getting enough sleep. Your mind and body need rest at the end of the day, and this can only be done with sleep. Your body isn’t a mechanical automaton, and that’s why it needs to rest and relax to maintain your health. To have good health is to have good sleep.

Nowadays our lives are fast-paced, and it’s difficult to keep up. This fast-paced lifestyle quickly builds stress, and that stress ultimately leads to depression if you’re not getting enough rest. If you don’t let your body rest, you’ll have difficulties in carrying out your daily routine. Therefore sleep is definitely an essential part of our lives and you can’t avoid it.

Needless to say, our body needs water more than anything else. 75% of our body weight contains water, and most of the internal and external bodily functions are carried out by water. Our body doesn’t want any deficit, especially in water. It could cause dehydration, and sickness, and could lead to death as well in severe cases.

Whenever our body is dehydrated, it starts to feel thirsty. Some scientists believe that our body is already dehydrated before we even feel thirsty. Because of thirst, we feel fatigued which lead to mind headache. Eventually, because of dehydration, we get sick. It could cause diarrhea, diabetes, kidney failure, coma, shock, heart stroke, electrolyte abnormalities, and many more.

What Water Does To Our Body

As repeatedly said, a multitude of bodily functions needs water.

• Regulates body temperature.
• Lubricates the joints of our body
• Protect Organs
• Flush out the wastes from our body
• It carries all the nutrients and oxygen.
• It dissolves minerals and nutrients.

Dehydration Effects On the Body

Even if we don’t start talking about what happens internally, we observe that it could cause mood swings, fatigue, and headaches. Less than one percent of dehydration could cause a negative effect on your overall bodily function.

Effect On Brain

Along with most of the functions of the body, dehydration is also related to our cognitive health, which includes our memory and attention. Dehydration changes the level of sodium and electrolyte level which affects many of the cognitive changes.

Though there are not many write-ups or literature available on how dehydration could affect the brain, it could cause short-term memory and attention as per Dr. Laura DeFina, MD, President.

Effect On Kidney

Water is responsible for removing waste from our blood as Urine. It ensures that the blood vessels are wide enough to carry out essential nutrients throughout the body. When our body gets dehydrated, the transportation system doesn’t work correctly, and it makes us feel tired.

Dehydration is severe enough to damage the kidney permanently. Our kidneys could clog muscle protein (myoglobin) and that hurts the kidneys. If the body is dehydrated regularly, it could lead to the formation of urinary tract infections and kidney stones.

Water prevents the crystals from sticking together inside the kidney and flushes them out, but it -needs enough water.

Water helps to make more Urine that usually flushes out germs and dissolves antibiotics. This prevents urinary tract infections in the

kidney.

Dark pale and strong odor urine indicates that your body needs more water. If you still see it very dark after having enough water, you must see the physician to take care of it.

Note: You might be restricted to intake a lot of water if you are going through kidney-related treatment or kidney failure. It is strongly recommended that the doctor’s suggestion should be taken seriously in that case.

Effect On the Cardiac System

Dehydration negatively affects our entire cardiac system, including heart rate, blood pressure, and hypertension. The risk of dehydration is higher in aged people and those who are suffering from chronic disease.

• Heart Rate Increases when your body gets dehydrated because the blood volume in the vessels decreases, which results in less stretch in the blood vessels. To compensate for the reduced amount of blood volume, the heart rate increases.
• Blood Pressure Increases may happen because of dehydration. Since it reduces the blood volume, the body retains more sodium in the blood. High levels of sodium could cause the contract or closing of small blood vessels in capillaries. When this happens, the blood becomes heavier and harder to circulate throughout the body, which increases the blood pressure.
• Cardiac Output Decreases are due to the effect on the heart rate and the blood volume in the vessels.
• Orthostatic Hypotension could occur due to dehydration because of the blood pressure increment. You might feel dizzy, light-headed, or even faint in some cases.

Effect Respiratory System

To digest and dissolve all the nutrients in the body, an adequate amount of water is mandatory. Drinking water strengthens the mucus lining and makes more space for to air move properly. Dehydration causes it to thicken and get sticky, and this stickiness results in the overall respiration system.

How Much Should I Drink?

Almost 90% of our body functions are dependent on water because of many factors. Especially our metabolism, diet, and body composition. Surprisingly, the amount of water could vary based on these factors too.

The first official document released in 2004 stated that an adult man should drink about 3.7 liters of water while women should drink about 2.7 liters of water per day. Furthermore, this document states that liquid items make up 80% of water intake.

Here’s how you can track your hydration.

• Always track the weight of your body and do not exceed the range of more than 1 percent of the baseline.
• You should be urinating about 3-4 times a day, and the color of your Urine shouldn’t be too pale or strong smell.
• Keep track of the fluids items in your daily diet. Consumption of fluid should be good enough, and it will prevent you from being thirsty.

Precautions:

• Whenever going outdoors, plan, and take extra water. People who work outside, the athletes must do this.
• Never forget to check the forecast, especially when the temperature is high. Avoid outdoor exposure, and exercise in the summer season.
• Young and older people, infants and children, are at the most risk. Be encouraged to intake enough amount of water.
• Alcohol consumption should be avoided, especially in the summer season as it causes loss of water.
• Avoid wearing dark clothes while it is hot outside. Wear light-colored and loose-fitting clothes when planning to go outdoors or exposed to direct sunlight.

It is crucial to take enough water intake, as we discussed. However, at any point in time, if you feel thirsty, you must drink water or fluid. Even after that, if you feel dizzy, fatigued, or headache, remember to reach out to a physician as quickly as possible. Stay hydrated, stay healthy. But before drinking water ensure that your drinking water is healthy and properly treated by a water purifier or water purification system.