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

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.

Susan Lillyman, Pauline Merrix