Effective record keeping is a sign of safe and skilled Nurses and Midwives, and is a legal requirement for all Healthcare 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.
Effective record keeping is a sign of safe and skilled Nurses and Midwives, and is a legal requirement for all Healthcare 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.
INTRODUCTION RECORDS Why records are needed? Types of records What makes a good record? What makes a poor record? Recording professional judgements Being objective in your records Using abbreviations How to amend entries if needed Electronic records Storage of records Patient held records Destruction of records. ACCESS TO RECORDS For the patient To solicitors To the court To the police To the media For research For a student After death PREPARING FOR THE LEGAL DEFENSIBILITY OF RECORD KEEPING CONFIDENTIALITY In records or conversations For course work The Caldicott report. Caldicott key principles. Disclosure. Consent to disclose CONSENT TO TREATMENT AND RECORD KEEPING How to assess competence/capacity. What to record in the health records concerning consent. Children and consent Loss of Capacity Consent: Disability Discrimination Act Right to withdraw/refuse consent ETHICS, ACCOUNTABILITY AND RECORD KEEPING MAINTAINING YOUR SKILLS FOR RECORD KEEPING RELEVANT LEGISLATION OTHER RECORDS Patients advanced statement Advanced decision Personal professional records CONCLUSION Scenarios 1-3: demonstrating public interest disclosure. Scenario 4: demonstrating record keeping with child consent. KEY REFERENCES USEFUL WEBSITES
INTRODUCTION RECORDS Why records are needed? Types of records What makes a good record? What makes a poor record? Recording professional judgements Being objective in your records Using abbreviations How to amend entries if needed Electronic records Storage of records Patient held records Destruction of records. ACCESS TO RECORDS For the patient To solicitors To the court To the police To the media For research For a student After death PREPARING FOR THE LEGAL DEFENSIBILITY OF RECORD KEEPING CONFIDENTIALITY In records or conversations For course work The Caldicott report. Caldicott key principles. Disclosure. Consent to disclose CONSENT TO TREATMENT AND RECORD KEEPING How to assess competence/capacity. What to record in the health records concerning consent. Children and consent Loss of Capacity Consent: Disability Discrimination Act Right to withdraw/refuse consent ETHICS, ACCOUNTABILITY AND RECORD KEEPING MAINTAINING YOUR SKILLS FOR RECORD KEEPING RELEVANT LEGISLATION OTHER RECORDS Patients advanced statement Advanced decision Personal professional records CONCLUSION Scenarios 1-3: demonstrating public interest disclosure. Scenario 4: demonstrating record keeping with child consent. KEY REFERENCES USEFUL WEBSITES
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