Record Keeping

Effective record keeping is a sign of safe and skilledNurses and Midwives and is a legal requirement for allHealthcare professionals. This pocket-sized guide provides you with the tools to write clear and concise records.The Nursing & Health Survival Guides have evolved - take a look at our our app for iPhone and iPad.

INTRODUCTIONRECORDS Why records are needed? Types of recordsWhat makes a good record?What makes a poor record?Recording professional judgementsBeing objective in your recordsUsing abbreviationsHow to amend entries if neededElectronic recordsStorage of recordsPatient held recordsDestruction of records.ACCESS TO RECORDSFor the patientTo solicitorsTo the courtTo the policeTo the mediaFor researchFor a studentAfter deathPREPARING FOR THE LEGAL DEFENSIBILITY OF RECORD KEEPINGCONFIDENTIALITY In recordsor conversationsFor course workThe Caldicott report.Caldicott key principles.Disclosure.Consent to discloseCONSENT TO TREATMENT AND RECORD KEEPING How to assess competence/capacity. What to record in the health records concerning consent. Children and consentLoss of Capacity Consent: Disability Discrimination ActRight to withdraw/refuse consent ETHICS, ACCOUNTABILITY AND RECORD KEEPINGMAINTAINING YOUR SKILLS FOR RECORD KEEPINGRELEVANT LEGISLATIONOTHER RECORDSPatients advancedstatementAdvanced decisionPersonal professional records CONCLUSIONScenarios 1-3: demonstrating public interest disclosure. Scenario 4: demonstrating record keeping with child consent. KEY REFERENCES USEFUL WEBSITES

Susan Lillyman, Pauline Merrix