Biomaterial Database

Exploring the principles of good record keeping in nursing. 2005

Bridgit Dimond

University of Glamorgan.

Record keeping is an integral part of patient care. This article considers the basic principles which should be followed in the light of guidance from the Department of Health, Nursing and Midwifery Council and the Clinical Negligence Scheme for Trusts. Apart from the Mental Health Act 1983 and abortion regulations there are few statutory provisions covering record keeping, but the courts would apply the Bolam Test of the reasonable standard of care to documentation.

UI	MeSH Term	Description	Entries
D009737	Nursing Records	Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress.	Records, Nursing,Nursing Record,Record, Nursing
D011361	Professional Competence	The capability to perform the duties of one's profession generally, or to perform a particular professional task, with skill of an acceptable quality.	Competence, Professional,Generalization of Expertise,Technical Expertise,Expertise Generalization,Expertise, Technical
D004282	Documentation	Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information.	Documentations
D005568	Forms and Records Control	A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records.	Records Control,Forms Control,Records Management,Controls, Records,Management, Records,Records Controls
D006113	United Kingdom	Country in northwestern Europe including Great Britain and the northern one-sixth of the island of Ireland, located between the North Sea and north Atlantic Ocean. The capital is London.	Great Britain,Isle of Man
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D012308	Risk Management	The process of minimizing risk to an organization by developing systems to identify and analyze potential hazards to prevent accidents, injuries, and other adverse occurrences, and by attempting to handle events and incidents which do occur in such a manner that their effect and cost are minimized. Effective risk management has its greatest benefits in application to insurance in order to avert or minimize financial liability. (From Slee & Slee: Health care terms, 2d ed)	Hospital Incident Reporting,Incident Reporting, Hospital,Hospital Incident Reportings,Incident Reporting,Incident Reportings, Hospital,Management, Risks,Reporting, Hospital Incident,Reportings, Hospital Risk,Voluntary Patient Safety Event Reporting,Hospital Risk Reporting,Hospital Risk Reportings,Incident Reportings,Management, Risk,Reporting, Hospital Risk,Reporting, Incident,Reportings, Hospital Incident,Reportings, Incident,Risk Reporting, Hospital,Risk Reportings, Hospital,Risks Management
D017408	Guidelines as Topic	Works about a systematic statement of policy rules or principles. Guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by convening expert panels. For guidelines in the field of health care and clinical medicine, PRACTICE GUIDELINES AS TOPIC is available.	Guidelines as Topics