Record Keeping on Patient Safety and Nursing Practice.
A record is a transaction between individuals or institutions that is first documented and then stored on a specific repository for a given, or in some cases an unspecified amount of time. Records vary in their contexts they can range from court records to state information that a country holds about its citizens i.e. birth and death certificates. Records in the current day and age are usually.
Nursing Practice Review Record-keeping well as a host of assessment tools to help assess risk relating to falls, pressure ulcers, phlebitis in cannula sites and skin integ-rity assessments. Investigations Clinical records are often used to establish what has happened when a serious inci-dent or complaint is raised. The purpose of the investigation is to establish a timeline or audit trail.
This article considers best practice in record-keeping and documentation in the light of recent public inquiries and reports, renewed national interest in record-keeping standards, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. The nature of the nurse-patient relationship is also changing, and should be reflected in nurses’ record.
There are standards throughout the Code that are indirectly related to record keeping practice. The following are specifically about record keeping practice: Prioritise People: 4.2 make sure that you get properly informed consent and document it before carrying out any action (Page 6) Practise Effectively.
This article aims to set the nursing practice of record-keeping in the context of recent public inquiries and guidance, as well as current policy and legislation. It discusses the risks.
Good record keeping is part of nursing care given to patients. As a matter of fact, it is almost impossible to memorize everything one does or everything that happens in a shift. Therefore, failure to have accurate and clear nursing records for all patients may make handover to new nursing teams incomplete. Furthermore, this may affect the patients well being. Quality of records kept by a.
Record keeping is an integral part of a nurse prescriber's care and treatment that is every bit as important as the direct care you provide to patients. Record keeping also has a vital legal purpose. It provides evidence of your involvement with patients and needs to be detailed enough to demonstrate that you have fulfilled your legal and professional duty of care. In this article, Richard.