Description
Effective record-keeping is essential to health care. This book is a handy pocket-sized guide to keeping good health records that treats the process as an integral part of your everyday practice.
Every healthcare practitioner is expected to record their interactions with a patient in the patient’s health record, and this pocket guide is full of practical detail about:
- what a health record is and what its purpose is
- how health records are managed
- who has access to health records
- the importance of maintaining a patient’s health record
- best practice in keeping records
Written by an experienced lecturer with input provided by current nursing students, this guidance is produced with you in mind – and you can carry it with you at all times!
Preface; About the author; Acknowledgements; Common terminology and key concepts
1. Health records
1.1 Defining health records
1.2 The purpose of health records
1.2.1 Clinical purposes
1.2.2 Non-clinical purposes
1.3 Components of a health record
2. Management of health records
2.1 Confidentiality of health records
2.1.1 Definition of confidentiality
2.1.2 Confidentiality: an overview of the law
2.1.3 Data Protection Act 2018
2.1.4 Confidentiality and regulation
2.2 Ownership of health records
2.2.1 NHS employed healthcare practitioners
2.2.2 Self-employed healthcare practitioners
2.2.3 Non-NHS employed healthcare practitioners
2.3 Storage of health records
2.3.1 How to store health records
2.3.2 Temporary notes
2.4 Retention periods
2.5 Destruction of health records
3. Access to health records
3.1 Patients reading their own health records
3.2 Accessing health records
3.2.1 Patients
3.2.2 Relatives
3.2.3 Healthcare practitioners
3.2.4 Administrative staff
3.2.5 Police
3.2.6 Own health records
3.3 Child patients and access to health records
3.3.1 The child patient
3.3.2 Individuals exercising parental responsibility
3.4 Accessing health records after the death of a patient
3.5 Concerns about providing access to a patient's health record
4. The standard for record-keeping
4.1 A standard for maintaining health records
4.1.1 Legal
4.1.2 Regulatory
4.1.3 Employer
4.1.4 Combined approach
4.2 Features of good record-keeping
5. Practical aspects of health records
5.1 Considerations when writing an entry in a health record
5.1.1 The right record
5.1.2 Signing and initialling entries
5.1.3 Language and style of entry
5.1.4 Personalised entries
5.1.5 Ink colour
5.1.6 Referring to other parts of the health record
5.1.7 Jargon and abbreviations
5.1.8 Electronic communications
5.2 Time pressures
5.3 Writing entries for colleagues
5.4 Changing an entry in a health record
5.5 Third party information
6. Best practice in record-keeping
6.1 Best practice pointers
6.2 A process for best practice
6.3 My top tip for best practice in record-keeping
References; Useful resources; Notes
Records and Record-keeping addresses all aspects of record keeping and documentation that student nurses need to know. The links to record keeping for child patients, the NMC code, data protection Act and process of accurate record keeping provides a very informative and concise reference for users.
Senior Lecturer, University of South Wales
