Records and Record keeping
Record keeping is considered by the UKCC to be a fundamental
part of nursing, midwifery and health visiting practice. Documentation
and maintenance of medical records thus forms an integral part of
care of expedition members. The following information is taken from
Guidelines for Records and Record
Keeping, UKCC 1998. This document should be referred to for
further information.
There is no single model for a record but there are
a number of key principles which underpin good records and record
keeping.
Content and Style
Patient records should:
- be factual, consistent and accurate
- be written as soon as possible after an event has occurred,
providing current information on the care and condition of the
patient
- be written clearly, accurately and be dated, timed and signed
- not include abbreviations, jargon, meaningless phrases or
irrelevant speculation
- be written in terms the patient can easily understand
Legal matters and complaints
Patient records are sometimes called in evidence before
a court of law. They may also be used in evidence by the UKCC Professional
Conduct Committee, which considers complaints about professional
misconduct by registered nurses, midwives and health visitors.
As a registered nurse, midwife or health visitor you
have both a professional and a legal duty of care. Your record keeping
should therefore be able to demonstrate:
- a full account of your assessment and the care you have planned
and provided
- relevant information about the condition of the patient at
any given time and measures taken to respond to their needs
- evidence that you have understood and honoured your duty of
care
Courts of law tend to adopt the approach to record
keeping that 'if it is not recorded, it has not been done'. Use
your professional judgment to decide what is relevant and what should
be recorded.
This may not seem particularly relevant in the middle
of the Amazon Rain Forest or a remote African village, but it is
important to remember that the UKCC Code of Professional Conduct
applies to all UKCC registered nurses wherever in the world they
are practising.
Access and ownership
You need to assume that any entries made in a patient
record will be scrutinized at some point. Patients have a legal
right to see their records, which are usually kept for at least
8 years.
You also have a duty to protect the confidentiality
of the patient record.
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