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Information governance: practical implications for record-keeping

Christine Hutchinson Consultant nurse, Learning disability, Preston Primary Care Trust, Preston

Christine Sharples Consultant nurse, Public health, Blackpool Primary Care Trust, Blackpool

This article outlines nurses’ legal and professional responsibility to adhere to good practice in keeping patients’ notes up to date. It provides a description of information governance issues, including paper and electronic records. The article discusses wider issues such as the importance of good communication in record-keeping and advises on good practice in content and style.

Nursing Standard. 20, 36, 59-64. doi: 10.7748/ns2006.05.20.36.59.c4155

Correspondence

christine.hutchinson@prestonpct.nhs.uk

Peer review

This article has been subject to double blind peer review

Keywords :

Clinical governance - Management information systems - Patients: records - Record-keeping