Key Features:

No. of pages: 58

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Table of Content:

CHAPTER ONE

INTRODUCTION



CHAPTER TWO

REVIEW OF RELATED LITERATURE



CHAPTER THREE

RESEARCH METHODOLOGY



CHAPTER FOUR

DATA ANALYSIS AND PRESENTATION



CHAPTER FIVE

DISCUSSION OF FINDINGS, SUMMARY AND CONCLUSION



References

Questionnaire

Introduction:

INTRODUCTION

1.0 Background of the Study

Patients' records provide a trace of care processes that have occurred and are further used as communication amongst health care workers for continued management of patients. Health care workers have the responsibility to ensure that records are accurate and complete in order to effectively manage their patients. In hospitals, health care workers have to record a wide range of information in the patient's records and this leads to increased workload on the part of health care worker that compromises accurate record-keeping.

Good record keeping of patient care practice requires detailed record-keeping that is comprehensive, timely and accurate. Without complete recording there is no evidence to prove that care was provided to the patient, and in health record keeping practice there is a saying that 'what is not recorded has not been done' (Marinic 2015; Taiye 2015). Furthermore, poor record-keeping not only undermines patient care but makes the health care worker more vulnerable to legal claims which arise from breakdown in communication that results from incomplete or inadequate records (Marinic, 2015). The South African Nursing Council (SANC) Rules and Regulation R387 relating to Acts and Omissions requires a health care worker to keep clear and accurate records of all actions done to the patient at all times and failure to do so constitutes a professional misconduct where the SANC may take disciplinary action against such staff (SANG 2005, R387 as amended).