Record Keeping for Nurses and Midwives: An essential guide (Original PDF from Publisher)

By Amanda Andrews and Bernie St Aubyn

For far too long, record-keeping has been viewed as an ancillary task to nursing care, often hastily completed at the end of a shift. However, good record-keeping is a vital professional obligation and an integral part of nursing care. Accurate records provide a crucial channel of communication between healthcare professionals, serving as evidence of the care provided, including the what, when, and how. This evidence is essential in protecting both nurses and patients, particularly in the event of complaints and legal proceedings.

The Role of Record-Keeping in Nursing Practice

The authors, with over ten years of experience in training nurses on record-keeping principles, emphasize the importance of reflective and critical thinking in record-keeping. They highlight the need for nurses to prioritize record-keeping as a crucial aspect of their daily practice, ensuring that records are well-documented, court-proof, and accepted by the legal profession.

Key Aspects of Good Record-Keeping

• General principles of record-keeping
• Court-proofing documents to withstand legal scrutiny
• Effective record-keeping in practice
• The increasing use of electronic patient record systems

To test your knowledge, a quiz is included to assess your understanding of record-keeping principles.

Book Details

Publisher: M&K Publishing
First Edition: September 21, 2020
Language: English
ISBN-10: 1905539258
ISBN-13: 978-1905539253

Good record-keeping is an essential skill for nurses, and this guide provides the necessary knowledge and tools to excel in this critical aspect of nursing care.