Record Keeping Interview

Documentation and render salvageing Aims and objectives To provide cultivation on softw be program documentation and record keeping To understand why records ar kept To examine statutory issues relating to record keeping To mount an thought of the standards required for documentation Documentation The writing of the patient record is an integral fictional character of the registered nurse, midwife & health flush Assistant The treat record is the pen evidence of nurse practice (Tapp 1990) if it is accurate, timely and comprehensive, it reflects reference address. Documentation The see principles for fiber records are outlined in Nursing and midwifery Council (NMC) guidelines (2009). unattackable record keeping - integral part of nursing and practice, and is prerequisite to the provision of safe and effective care. It is not an elective unornamented to be fitted in if circumstances allow. (NMC 2009) Why keep quality records?

Greater involvement of patients in making choices somewhat care Patient centred care Patients having access to their own records engine mode Clinical audit Clinical negligence Poor record keeping distant remarks Abbreviations Undermines patient care Makes you vulnerable to legal and superior problems Increases your work load Vague comments reasonable, fitting Guidelines for practice Frequency of entries should be dogged by professional judgement and local standards. Records need to take on a logical sequence with clear milestones and goals. Things that have not been make need to be documented as well(p) as those that have. Registered nurses are not professionally accountable for entri es do by savant nurses and healthcare assi! stants Patient records should: Be factual, invariable and accurate Be scripted as soon as possible after(prenominal) an event has occurred Provide current information on the care and condition of the patient Dated, timed and subscribe with the signature printed on board the first entry Be written in name the patient can understand, and...If you want to pop out a full essay, order it on our website: OrderEssay.net

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