title: Maintaining best practice in record-keeping and documentation.
abstract: This article considers best practice in record-keeping and documentation in the light of recent public inquiries and reports, renewed national interest in record-keeping standards, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. The nature of the nurse-patient relationship is also changing, and should be reflected in nurses' record-keeping practices. Collaborative approaches to the planning and evaluation of care, and more emphasis on patients having a greater sense of ownership of information held about them should be reflected in nurses' and other healthcare professionals' attitudes and approaches to this aspect of practice.
authors.affiliation: West Bromwich.
authors.forename: Jane
authors.initials: J
authors.lastname: Beach
authors.forename: Jennifer
authors.initials: J
authors.lastname: Oates
mesh_terms: D004282:Documentation / Q000379:methods / Q000592:standards*; D057286:Electronic Health Records / Q000592:standards*; D017410:Practice Guidelines as Topic; D006113:United Kingdom