What are the guidelines for record keeping and documentation as per nursing and Midwifery Council?

Principles of Good Record Keeping

• Be factual, consistent and accurate;
• Be updated as soon as possible after any recordable event;
• Provide current information on the care and condition of the patient;
• Be documented clearly in such a way that the text cannot be erased;

What does NMC say about record keeping?

The Code of Professional Conduct (NMC, 2002a) advises that good note-taking is a vital tool of communication between nurses. It states that nurses ‘must ensure that the health care record for the patient or client is an accurate account of treatment, care planning and delivery.

When did it become a legal requirement for nurses and midwives to hold an indemnity arrangement?

Professional indemnity arrangement to become legal requirement for registered nurses and midwives. The legislation is expected to come into force by the end of October 2014.

What is record keeping in NHS and nursing?

The purpose of records is to provide a clear and precise account of the patient’s healthcare journey and reflect the practitioner’s assessment, planning and evaluation processes. The Nursing and Midwifery Council (NMC) sets out a nurse’s obligation in the Code to keep clear and accurate records relevant to practice.

Which act is related to record keeping?

The legal requirements for the keeping of records are set out in Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) 2010.

What is the purpose of record keeping?

Why keep records? Records contain information that is needed for the day to day work of government. Their purpose is to provide reliable evidence of, and information about, ‘who, what, when, and why’ something happened.

What is indemnity cover for nurses?

Professional nurse indemnity insurance, also known as nursing professional indemnity insurance, nursing liability insurance or nurse malpractice insurance, is insurance coverage that protects nurses from lawsuits in the event an incident or negligence claim arises.

Are you professionally accountable as a student nurse?

Registered nurses, midwives and registered nursing associates are professionally accountable to the Nursing and Midwifery Council (NMC). The law imposes a duty of care on practitioners, whether they are HCAs, APs, nursing associates, students, registered nurses, doctors or others.

What is recording and reporting in nursing?

 A record is a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family or community.  Reports are oral or written exchanges of information shared between caregivers or workers in a number of ways.

What are the four purposes of medical records?

Healthcare organizations maintain medical records for several key purposes:

• Patient Care. Patient records provide the documented basis for planning patient care and treatment.
• Communication.
• Legal documentation.
• Billing and reimbursement.
• Research and quality management.

What should be in a therapy progress note?

In general, BIRP notes should include the following information:

• Behavior: The counselor’s observations and the patient’s statements, including direct quotes or paraphrased information.
• Intervention: The methods used to address the patient’s goals, statements and observations.

How are nurses and midwives supposed to keep records?

Record keeping: Guidance for nurses and midwives The way in which nurses and midwives keep records is usually set by their employer. The Nursing and Midwifery Council (NMC) recognises that, because of this, nurses and midwives may use diff erent methods for keeping records. However, the principles

Why is record keeping important for nursing professionals?

Record-keeping is an integral part of Nursing, Midwifery and Allied Health Professionals’ practice and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow (NMC 2009).

How many nurses and midwives are there in the UK?

We’re the professional regulator of almost 732,000 nurses, midwives and nursing associates. Our vision is safe, effective and kind nursing and midwifery care for everyone.

What kind of records should a nursing home have?

Clear copies of relevant records. This could include patient notes, care plans, and medication administration records. Evidence of staffing levels at the relevant time and what the expected staffing level was, including rotas and details of handovers.