Information governance: practical implications for record-keeping.
This article outlines nurses' legal and professional responsibility to adhere to good practice in keeping patients' notes up to date. It provides a description of information governance issues, including paper and electronic records. The article discusses wider issues such as the importance of good communication in record-keeping and advises on good practice in content and style.
Hutchinson
Christine
C
Preston Primary Care Trust. christine.hutchinson@prestonpct.nhs.uk
Sharples
Christine
C
D003219:Confidentiality; D004282:Documentation / Q000592:standards; D006801:Humans; D008499:Medical Records; D009313:National Health Programs; D024802:Nurse's Role; D006113:United Kingdom