This document discusses nursing documentation and record keeping. It outlines the learning outcomes of understanding best practices in documentation and the Nursing and Midwifery Council's principles of good record keeping. Clinical records are used to provide patient care but also in litigation cases and root cause analyses of medical incidents. Registered nurses are accountable to regulatory bodies, employers, courts, patients and their families for documentation.

1. UNIT 11
DOCUMENTATION
ANISA FATMALA
:1414401D004
AULIA AZIZAH:
1414401D006
FITRIA NURJANNAH:
1414401D014

2. CHAPTER 11
• LEARNING OUTCOMES
By the end of this chapter you will have an
understanding of the best practice in nursing
documentation, record keeping and written
communication. Effective record-keeping is
essential to facilitate robust communication
between healthcare professionals.

3. • NURSING AND MIDWIFERY COUNCIL
The Nursing and Midwifery Council (or
NMC) is the UK regulator that safeguards the
health and wellbeing of the public, and strives
towards the consistent delivery of high-quality
health care. The NMC’s vision, mission and
values also include nursing and midwifery
students.

4. The NMC (2009) has also issued guidance for the
principles of good record-keeping, stating that:
1 . Handwriting should be legible.
2. All entries to records should be signed. In the
case of written records, the person’s name and job
title should be printed alongside the fi rst entry.
3 .In line with local policy, you should put the date
and time on all records. This should be in real
time and chronological order and be as close to
the actual time as possible.
4. Your records should be accurate and recorded in
such a way that the meaning is clear.
5. Records should be factual and not include

5. 4. Your records should be accurate and recorded
in such a way that the meaning is clear.
5. Records should be factual and not include
unnecessary abbreviations,
jargon,meaningless phrases or irrelevant
speculation.
6. You should use your professional judgement
to decide what is relevant and what should be
recorded.
7. You should record details of any assessments
and

6. reviews undertaken and provide clear evidence
of the arrangements you have made for future
and ongoing care. This should also include
details of information given about care and
treatment.
8. Records should identify any risks or problems
that have arisen and show the action taken to
deal with them.

7. 9. You have a duty to communicate fully and
effectively with your colleagues, ensuring that
they have all the information they need about
the people in your care.
10 .You must not alter or destroy any records
without being authorised to do so.

8. 11 .In the unlikely event that you need to alter your
ownor another healthcare professional’s records,
youmust give your name and job title, and sign
and date the original documentation. You should
make sure that the alterations you make, and the
original record, are clear and auditable.
12. Where appropriate, the person in your care, or
their carer, should be involved in the record-
keeping process.
13. The language that you use should be easily
understood by the people in your care. Records
should be readable when photocopied
orscanned.

9. 15 You should not use coded expressions of
sarcasm or humorous abbreviations to
describe the people in your care.
16 You should not falsify records.

10. • LEGAL ISSUES
Clinical records are part of the ongoing process
of providing the correct patient care, but are
frequently seen by nurses as a means of
providing evidence for use in litigation cases,
and are written in this style.

11. • ROOT CAUSE ANALYSIS
When mistakes occur in the clinical setting, the
clinical nrecords are viewed as part of the
investigation. This investigation is referred to
as a root cause analysis whereby the incident
is investigated in full, looking at what
happened and when, what actions were taken
and why they were taken.

12. • ACCOUNTABILITY
According to the NMC (2008), registered nurses
areaccountable to:
• the NMC to demonstrate fi tness to practice and
adherence to the code of conduct;
• their employer or trust to demonstrate fulfi lment of
their contractual agreement and that
they are performing at the right standard for their role;
• the courts if there are claims of negligence or
criminalacts (law);
• the patient and family.

13. • NURSING DOCUMENTATION
Within the healthcare profession, whether you
work in a hospital, care home or community
setting, you will see many different charts,
forms and types of documentation.