Abstract
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.