Exploring the principles of good record keeping in nursing.
Record keeping is an integral part of patient care. This article considers the basic principles which should be followed in the light of guidance from the Department of Health, Nursing and Midwifery Council and the Clinical Negligence Scheme for Trusts. Apart from the Mental Health Act 1983 and abortion regulations there are few statutory provisions covering record keeping, but the courts would apply the Bolam Test of the reasonable standard of care to documentation.
Dimond
Bridgit
B
University of Glamorgan.
D004282:Documentation / Q000592:standards*; D005568:Forms and Records Control / Q000331:legislation & jurisprudence / Q000592:standards; D017408:Guidelines as Topic; D006801:Humans; D009737:Nursing Records / Q000331:legislation & jurisprudence / Q000592:standards*; D011361:Professional Competence / Q000331:legislation & jurisprudence / Q000592:standards; D012308:Risk Management / Q000331:legislation & jurisprudence / Q000592:standards; D006113:United Kingdom