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.
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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
