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