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Summary
Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. It also provides legal evidence. This article highlights the advantages of accurate record keeping and the barriers to effective documentation in the community setting.
Keywords
District nursing; Documentation; Record keeping
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THE DATA PROTECTION Act 1998 defines a health record as any electronic or paper information recorded about a person for the purpose of managing his or her health care. Guidelines for records and record keeping published by the Nursing and Midwifery Council (NMC 2002) state that: 'good record keeping is a mark of the skilled and safe practitioner'. Record keeping promotes better communication between members of the primary healthcare team, accounts for care planning and delivery of treatment, and enables changes in the patient's condition to be detected (NMC 2002).
Standards for record keeping
While recognising that record keeping is an integral part of nursing and promotes good practice, the NMC provides little guidance on how records should be written (Griffith 2004). However, it would be unrealistic to assume that a standard universal record might emerge to meet the information needs of all practitioners and adhering to basic principles is recommended (Charles et al 2000).
Records should provide factual, current, comprehensive and consistent information about the assessment and care of patients (NMC 2002). Records should be written chronologically and dated and signed by the practitioner in a manner that cannot be erased, and is legible on photocopies. In addition, the Guidelines for Records and Record Keeping state that abbreviations and jargon must not be used and records should be written, whenever possible, with the involvement of the patient (NMC 2002).
The Access to Health Records Act 1990 gives patients the right to view and receive written records. This legal proceeding could be prevented if records are written with the...