The ability to communicate well is an essential skill for medical and nursing staff (Moore, 2005).It is important that principles of effective communication are utilised. The initial contact that the Gilliam’s had where they met a nurse and were informed that the facility was not open, payment would be required and they should return in the morning was not true communication.Both the Australian Medical Association (2004) and the Australian Nursing and Midwifery Council (2008) in their Code of Ethics have the first consideration as the well-being of the patient.
Like the implementation of health and safety regulations, it is not easy to ensure that there is always a reasonable standard of record keeping: there are peaks and troughs depending on the priority given to record keeping and the competing pressures for the time of registered practitioners.
In this case the Career Medical Officer could not be questioned as to the intent of his documentation and it was inconsistent with the recall of the Medical Registrar.
Therefore it is vital that every entry should stand independently and provide enough information so a new care giver reviewing the medical record would know exactly what the patient was being seen for, their course of treatment and the doctor’s plan of action (Murphy 2001).
However, it must always be remembered that records and record keeping are an intrinsic part of the professional activities of a registered practitioner, not an optional extra.
The coroner report investigating Mr Gillam’s death does not specifically question the ethical decision-making of either the nursing or medical staff; however I believe that some questions should have been asked.