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Record Keeping In Nursing Essay Example


There are many reasons for keeping records in health care, but two stand out above all others:

  • to compile a complete record of the patient’s/client’s journey through services
  • to enable continuity of care for the patient/client both within and between services.

The records we keep in health care need to be clear, accurate, honest and timely (meaning they should be written as near as possible to the actual time of occurrence of the events they describe).

Different means of record-keeping are used in health care settings. Some workplaces use hand-written records, others have moved to computer-based systems, and many use a combination of both. You’ll be expected to be able to comply with whatever requirements your employer sets for record-keeping, be it hand-written or electronic. That means you’ll need to:

  • know how to use the information systems and tools in your workplace
  • protect, and do not share with anyone, any passwords or ‘Smartcards’ given to you to enable you to access systems
  • make sure written records are not left in public places where unauthorised people might see them, and that any electronic system is protected before you sign out.

There are principles of record-keeping that we will look at in this section, chief among which is the need to protect patients/clients confidentiality. The RCN has provided some guidance on record keeping called `Delegating record keeping and countersigning records’.

But before we begin to explore these principles, we should be aware that apart from being clear, accurate, honest and timely about what we write, we also need to be careful. This means we have to ensure that nothing we write is, or could be interpreted as being:

  • insulting or abusive
  • prejudiced
  • racist, sexist, ageist or discriminatory in any way.

1. Milieu Ltd, Time.lex. Overview of the national laws on electronic health records in the EU member states and their interaction with the provision of cross-border eHealth services. Brussels, Consumers, health and food executive agency (Chafea), 2014. Available from: http://ec.europa.eu/health/ehealth/docs/laws_report_recommendations_en.pdf Date last accessed: September 20, 2016.

2. Good medical practice. Manchester, General medical council, 2013. Available from: www.gmc-uk.org/static/documents/content/GMP_.pdf Date last updated: April 29, 2014. Also available from: www.gmc-uk.org/guidance/good_medical_practice.asp Date last accessed: September 20, 2016.

3. The Code. London, Nursing and midwifery council, 2015; p. 9. Available from: www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf Date last accessed: November 04, 2016.

4. Confidentiality of certain medical records. US code of laws, title 38, part V, chapter 73, subchapter III, § 7332. Available from: www.gpo.gov/fdsys/pkg/USCODE-2011-title38/pdf/USCODE-2011-title38-partV-chap73-subchapIII-sec7332.pdf

5. Pullen I, Louden J. Improving standards in clinical record keeping. Adv Psychiatr Treat 2006; 12: 280–6.

6. Confidentiality. Manchester, General medical council, 2009. Available from: www.gmc-uk.org/static/documents/content/Confidentiality_-_English_1015.pdf Also available from: www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp. Date last accessed: September 20, 2016.

7. (Model) professional code for physicians in Germany, article 10, obligation to keep medical records. Kiel, 114th German medical assembly, 2011. Available from: www.bundesaerztekammer.de/fileadmin/user_upload/downloads/MBOen2012.pdf Date last accessed: September 20, 2016.

8. Bundesärztekammer, Kassenärztliche bundesvereinigung. Empfehlungen zur ärztlichen schweigepflicht, datenschutz und datenverarbeitung in der arztpraxis. Deutches Ärzteblatt 2014; 111: A963–A972. Available from: www.bundesaerztekammer.de/fileadmin/user_upload/downloads/Schweigepflicht_2014.pdf. Date last accessed: September 20, 2016.

9. Health and social care information centre (HSCIC), Academy of medical royal colleges. Standards for the clinical structure and content of patient records. London, HSCIC, 2013. Available from: www.rcplondon.ac.uk/projects/outputs/standards-clinical-structure-and-content-patient-records Date last accessed: September 20, 2016.

10. Clinical guidance (CG2)-record keeping guidelines. Watford, NHS professionals ltd, 2016; version 5. Available from: www.nhsprofessionals.nhs.uk/Download/CG2%20-%20Record%20Keeping%20Guidelines%20V5%202016.pdf. Date last accessed: November 04, 2016.

11. Dossier professionnel ou fiche d’observation, tenu par le médecin. Article R.4127-45 du code de la santé publique Paris, Conseil national de l’ordre des médecins; Available from: https://www.conseil-national.medecin.fr/article/article-45-fiche-d-observation-269#article Date last accessed: September 20, 2016.

12. Code de déontologie médicale. Paris, Conseil national de l’ordre des médecins, 2016. Available from: www.conseil-national.medecin.fr/sites/default/files/codedeont.pdf Date last accessed: September 20, 2016.

13. ΣΧΕΣΕΙΣ ΙΑΤΡΟΥ ΚΑΙ ΑΣΘΕΝΗ. Κώδικας Ιατρικής Δεοντολογίας, ΚΕΦΑΛΑΙΟ Γ΄, Άρθρο 11-14 (ΦEK A/287 (NOMOΣ ΥΠ’ΑΡΙΘ. 3418/2005) Θεσσαλονίκης, Ιατρικός Σύλλογος Θεσσαλονίκης Available from: www.isth.gr/?page=2630. Date last accessed: September 20, 2016.

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