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This essay will discuss Record Keeping as reviewed by the student in relation to the clinical records of a client whilst on placement. It will explore quality issues as well as the effectiveness of clinical records in relation to National and Local Guidelines. Young (1995 p.179) defines record keeping as “any permanent form of information recorded about a client or patient”. Section 68 (2) Data Protection Act (1998) defines a Health Record as anything which: (a) “ consists of any information relating to the physical or mental health or condition of and individual” (b )“ has been made by or on behalf of a health professional in connection with the care of that individual” In practice record keeping is a professional multidisciplinary process and errors in record keeping have long been recognised as one of the high risk areas of nursing. Where there is a breakdown within the system it can lead to devastating consequences, for both the patient and the practitioner, with the nurse being frequently left accountable. Student nurses and nurses are constantly aware of the needs of patients and the importance of safe practice and are equally aware of the continuing increase in litigation concerning such issues. Therefore documentation is of paramount importance in both providing a means of communication and a written record in defence of the nurses actions. In recognition, the Nursing and Midwifery Council ( NMC, 2002) as the regulatory body for nursing have laid down guidelines for record keeping which include that records should: • Be factual, consistent and accurate • Be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient or client • Be written clearly and in such a manner that the text cannot be erased • Be accurately dated, timed and signed, with the signature printed alongside the first entry • Not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statement.
Approximate Word count = 1099
Approximate Pages = 4.4
(250 words per page double spaced)
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