Maintaining best practice in record-keeping and documentation
Jane Beach Professional officer for regulation, Unite/Community Practitioners and Health Visitors Association, West Bromwich
Jennifer Oates Freelance regulatory policy and research consultant, Brighton
This article considers best practice in record-keeping and documentation in the light of recent public inquiries and reports, renewed national interest in record-keeping standards, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. The nature of the nurse-patient relationship is also changing, and should be reflected in nurses’ record-keeping practices. Collaborative approaches to the planning and evaluation of care, and more emphasis on patients having a greater sense of ownership of information held about them should be reflected in nurses’ and other healthcare professionals’ attitudes and approaches to this aspect of practice.
Nursing Standard. 28, 36, 45-50. doi: 10.7748/ns2014.05.28.36.45.e8835Peer review
This article has been subject to double blind peer review
Received: 05 February 2014
Accepted: 10 March 2014