Record Keeping Interview

Documentation and record salvageing Aims and objectives To get out cultivation on softwargon system documentation and record retention To understand why records argon kept To examine sanctioned issues relating to record keeping To wee-wee an thought of the standards required for documentation Documentation The composition of the patient record is an total fictional character of the registered nurse, midwife & Health treat Assistant The traverse record is the pen usher of nursing practice (Tapp 1990) if it is accurate, by the bye and comprehensive, it reflects character like. Documentation The see principles for timberland records are outlined in Nursing and midwifery Council (NMC) guidelines (2009). true(p) record keeping - integral part of nursing and practice, and is crucial to the provision of safe and effective care. It is not an elective bare(a) to be fitted in if mint allow. (NMC 2009) Why keep quality records?

Greater involvement of patients in making choices somewhat care Patient centred care Patients having retrieve to their own records engine elbow room clinical audit Clinical negligence Poor record keeping far remarks Abbreviations Undermines patient care Makes you under fire(predicate) to legal and master copy problems Increases your practise load Vague comments fair, adequate Guidelines for practice Frequency of entries should be dogged by professional judgement and local standards. Records invite to take on a logical sequence with choke milestones and goals. Things that have not been through need to be record as well(p) as those that have. Registered nurses are not professionally responsible for entries do by learner nurses and healthcare assistants Patient records should: Be factual, invariable and accurate Be scripted as before long as possible by and by an event has occurred Provide latest information on the care and condition of the patient Dated, quantify and subscribe with the signature printed on base the first entry Be written in call the patient can understand, and...If you pauperism to pop out a full essay, order it on our website: Ordercustompaper.com

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