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Record Keeping


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Table of Contents

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 RECORDS For the patientTo solicitorsTo the courtTo the policeTo the mediaFor researchFor a studentAfter deathPREPARING FOR THE LEGAL DEFENSIBILITY OF RECORD KEEPINGCONFIDENTIALITY In records or 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 advanced statementAdvanced decisionPersonal professional records CONCLUSIONScenarios 1-3: demonstrating public interest disclosure. Scenario 4: demonstrating record keeping with child consent. KEY REFERENCES


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This pocket-sized guide provides you with the tools to write clear and concise records - a sign of safe and skilled Nurses and Midwives and a legal requirement for all Healthcare professionals.


"Another pocket-sized guide in the Pearson survival guide range which would be incredibly useful out in placement." - Nursing Student

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