The following guidelines for healthcare practitioners are helpful for staying within the scope of practice while operating within the law and policy of any healthcare facility.
- Practice within the scope of your training and capabilities.
- Use the professional title commensurate with your education and experience.
- Maintain confidentiality
- Prepare and maintain health records.
- Document accurately
- Use appropriate legal and ethical guidelines when releasing information.
- Follow an employer’s established policies dealing with the health care contract.
- Follow legal guidelines and maintain awareness of health care legislation and regulations.
- Maintain and dispose of regulated substances in compliance with government guidelines.
- Follow established risk management and safety procedures.
- Meet the requirements for professional credentialing.
- Help develop and maintain personnel, policy, and procedure manuals.
Select 2 of these and discuss why they are important for building effective provider/patient relationships and maintaining a standard of care. Are there other guidelines you would add to this list? Use examples based on your experiences.
Use APA formatting and citation standards. Use at least two (2) scholarly references published within the last 5 years to substantiate your work.
Title: Importance of Maintaining Confidentiality and Documenting Accurately in Provider/Patient Relationships
Introduction: In healthcare settings, maintaining effective provider/patient relationships and upholding a high standard of care are crucial for patient satisfaction, trust, and overall healthcare outcomes. Two key guidelines that contribute to these goals are maintaining confidentiality and documenting accurately. This discussion will highlight the importance of these guidelines and provide examples to illustrate their significance. Additionally, other guidelines will be suggested to enhance the list.
- Maintaining Confidentiality: Maintaining patient confidentiality is essential for building trust and preserving the provider/patient relationship. Patients disclose sensitive personal and medical information to healthcare practitioners with the expectation that it will remain confidential. Breaching confidentiality can lead to a breakdown in trust, reluctance to disclose crucial information, and potential harm to patients. Respect for patient privacy fosters a safe and supportive environment for open communication.
Example: A patient visits a psychiatrist seeking treatment for depression. The patient shares details about their mental health history, including past suicide attempts. If the psychiatrist were to breach confidentiality by sharing this information without consent, it could have severe consequences. The patient may feel betrayed and be hesitant to seek help in the future, hindering their access to appropriate care.
- Documenting Accurately: Accurate documentation is vital for continuity of care, communication among healthcare providers, and legal and regulatory compliance. It ensures that the patient’s medical history, assessments, treatments, and outcomes are well-documented and readily accessible to the healthcare team. Accurate documentation facilitates effective collaboration, reduces medical errors, and provides a comprehensive overview of the patient’s healthcare journey.
Example: A nurse caring for a patient in a hospital setting must accurately document vital signs, medication administration, and any changes in the patient’s condition. If the nurse fails to document vital signs correctly or neglects to record administered medications, it can lead to miscommunication among the healthcare team, jeopardize patient safety, and compromise the accuracy of subsequent interventions.
Additional Guidelines to Enhance the List:
- Cultivate Empathy and Effective Communication: Encouraging healthcare practitioners to develop empathetic communication skills can significantly impact the provider/patient relationship. Empathy fosters understanding, compassion, and patient-centered care, promoting positive healthcare experiences and outcomes.
- Practice Cultural Sensitivity and Respect: Recognizing and respecting diverse cultural beliefs and practices is crucial for providing patient-centered care. Healthcare practitioners should be knowledgeable about cultural nuances, customs, and preferences to deliver respectful and appropriate care.
Conclusion: Maintaining confidentiality and documenting accurately are crucial guidelines for healthcare practitioners to build effective provider/patient relationships and maintain a high standard of care. By respecting patient privacy and ensuring accurate documentation, healthcare professionals foster trust, enable continuity of care, and reduce the risk of medical errors. Additionally, incorporating guidelines such as cultivating empathy and practicing cultural sensitivity can further enhance the quality of care and patient satisfaction. Adhering to these guidelines promotes positive healthcare experiences and better patient outcomes.
References:
- Buppert, C. (2018). Nurse Practitioner’s Business Practice and Legal Guide (6th ed.). Jones & Bartlett Learning.
- Joint Commission on Accreditation of Healthcare Organizations. (2022). National patient safety goals. Retrieved from https://www.jointcommission.org/standards/national-patient-safety-goals/