Chapter 12. Record Keeping

  1. Philip Jevon RGN, BSc (Hons), PGCE, DiPSiN Resuscitation Officer Honorary Clinical Lecturer
  1. Philip Jevon RGN, BSc (Hons), PGCE, DiPSiN Resuscitation Officer Honorary Clinical Lecturer

Published Online: 19 OCT 2009

DOI: 10.1002/9781444315271.ch12

Care of the Dying and Deceased Patient: A Practical Guide for Nurses

Care of the Dying and Deceased Patient: A Practical Guide for Nurses

How to Cite

Jevon, P. (2009) Record Keeping, in Care of the Dying and Deceased Patient: A Practical Guide for Nurses (ed P. Jevon), Wiley-Blackwell, Oxford, UK. doi: 10.1002/9781444315271.ch12

Editor Information

  1. Manor Hospital, Walsall, UK

Author Information

  1. Manor Hospital, Walsall, UK

  1. This chapter is based on the chapter ‘Record Keeping’, which first appeared in Monitoring the Critically Ill Patient by Jevon & Ewens (2007).

Publication History

  1. Published Online: 19 OCT 2009
  2. Published Print: 13 NOV 2009

ISBN Information

Print ISBN: 9781405183390

Online ISBN: 9781444315271

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Keywords:

  • record keeping - integral part of nursing, midwifery and health visiting practice;
  • understanding good record keeping;
  • principles of good record keeping;
  • legal issues associated with record keeping;
  • NMC statement on record keeping;
  • common deficiencies in record keeping;
  • comprehensive nursing assessment of patient;
  • Access to Health Records Act 1990 - patients right of access to their manually maintained health records;
  • The Code, Standards of Conduct, Performance and Ethics for Nurses and Midwives;
  • record keeping - kept confidential and secure

Summary

This chapter contains sections titled:

  • Introduction

  • Learning Outcomes

  • Importance of Good Record Keeping

  • Common Deficiencies in Record Keeping

  • Principles of Good Record Keeping

  • Legal Issues Associated with Record Keeping

  • NMC Statement on Record Keeping

  • Conclusion

  • References