Record Keeping
1st Edition
Published on 11. September 2014
42 pages
978-1-317-90581-3 (ISBN)
Description
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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The Nursing & Health Survival Guides have evolved - take a look at our our app for iPhone and iPad.
More details
Series
Language
English
Place of publication
London
United Kingdom
Publishing group
Taylor & Francis Ltd
Target group
College/higher education
File size
1,47 MB
ISBN-13
978-1-317-90581-3 (9781317905813)
Copyright in bibliographic data and cover images is held by Nielsen Book Services Limited or by the publishers or by their respective licensors: all rights reserved.
Schweitzer Classification
Other editions
Additional editions
Susan Lillyman | Pauline Merrix
Nursing & Health Survival Guide: Record Keeping
Book
05/2012
1st Edition
Pearson Education Limited
€12.37
Shipment within 10-20 days
Persons
Susan Lillyman, Pauline Merrix
Content
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
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
