Supporting Patient Autonomy

Informed consent

At the heart of a respectful relationship between a patient and a provider of healthcare lies the principle of shared decision making. And informed consent is its practical application. There are some ethical principles of informed consent that are universal and which both patients and medical staff can anticipate and demand.

The fundamental idea at the heart of informed consent is patient autonomy. It is the right of patients to make informed decisions about their medical care and requires the medical staff to ask for permission before providing services or treatment. Medical providers are obligated to respect their patient’s autonomy, and cannot force choices upon them or make decisions without their agreement. However, they can educate the people in their care and provide them with the knowledge needed to make an informed choice on the matters of health (Entwistle, Carter, Cribb & McCaffery, 2010).

Veracity is the direct consequence of respect for persons and their autonomy and is the principle of providing the patient with clear, truthful, relevant, and complete information so that they can make rational educated decisions. This principle of truth-telling can be broken by lying, deliberately providing incorrect information, or by omitting information that could affect decision making. Finally, obscuring information with medical jargon or vague language is also considered denying patients veracity.

Doctors and nurses have to balance veracity with paternalism. Paternalism expects health care professionals to make judgments about what is best for the patient, including withholding information if medical staff believes that it can adversely affect him or her.

Finally, there is the principle of justice to be considered. It demands that all patients are to be treated justly and equally. This affects questions of nurse’s time attention distribution among patients, and the allocation of resources (Phang 2014).

Effective Documentation and Electronic Medical Record

All materials about nurses maintaining effective documentation point to the importance of good record keeping practices. While it may seem like a distraction from the actual nursing work and caretaking for the patients to the uneducated eye, in reality, it is one of the critical parts of nursing care provided to the patients.

Two findings should be considered when evaluating the importance of effective documentation. First of all, a patient’s nursing record is vital for creating a treatment strategy, establishing past medical history, and maintaining rapport and communication between different nurses, and between them and doctors. Secondly, the quality of nursing records is a reflection of the quality of care provided to the patients. Nursing records might prove to be the only proof that treatment was applied to the patient, and can save a nurse from a lot of scrutiny in the case of a complaint.

However, the legal importance that the notes and reports have in court was a discovery to me and gave the issue a new perspective. Effective documentation and records keeping can save a nurse many problems, should one of the patients file a complaint (Stokowsk, 2013).

For these reasons, electronic medical records have several advantages over paper documentation both from a legal and nurses’ perspective. Electronic charting eliminates misunderstandings between nurses, and allows them to access relevant information faster, and is more eligible for legal evaluations.

I have observed these benefits by working with the Epic EMR. It indeed improves access to information, allows for better patient time management, easier recovery of medical history. However, there are also notable problems, most of which are tied to the inefficiency of hardware and not yet streamlined format of the software. Information charting requires a lot of time to be allocated to it, which creates delays and takes time out of actual patient care. Despite its benefits, at the moment, it is neither patient nor nurse friendly.

References

Entwistle, V. A., Carter, S. M., Cribb, A., & McCaffery, K. (2010). Journal of General Internal Medicine, 25(7), 741–745. Web.

Phang, K. (2014). 7 Key Ethical Principles of Nursing. Web.

Stokowsk, L. A. (2013). Web.

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