Nurses must carefully maintain patient medical records to avoid legal issues. Records should be kept securely under nurse custody, without separating individual sheets. Confidential patient information must be protected and records not made accessible to unauthorized people. Records should include identifying patient information and any alterations or copies must be clearly indicated, following facility policies. Proper documentation principles like date, time, legibility, and accuracy should be followed. Computerized records also require maintaining confidentiality, not disclosing passwords, and not deleting information without authorization.

1. By:
Mr. M.Shivananda Reddy

2. As the records are the proof of care and legal
documents the records have to be maintained
appropriately to avoid legal complications.
The nurse has to take the following measures:
• Keep the records under safe custody of nurses.
• No individual sheet should be separated.
• Maintain the confidentiality of the information
• Don’t make accessible to other patients and
visitors.

3. • Strangers are not permitted to read records.
• Records are not handed over to the legal advisors
without written permission of the administration.
• Handed carefully, not destroyed
• Identified with bio-data of the patients such as
name , age, admission number, diagnosis, etc.
• Never sent outside of the hospital without the
written administrative permission.
• Send the records to medical record department
(MRD) for the further usage

4. • YOU SPILL SOMETHING ON THE CHART, DO NOT
DISCARD NOTES. RECOPY, PUT ORIGINAL AND
COPIED SHEETS IN CHART. WRITE “COPIED” ON
COPY.
• DO NOT SCRIBBLE OUT CHARTING.
• FOLLOW YOUR FACILITIES POLICY.
• DO NOT ALTER CHARTING, IT IS A LEGAL
DOCUMENT.

5. The documentation in the records has to be made by following
the principles of recording like:
• Date & time
• Timing
• Legibility
• Permanence
• Correct spelling
• Signature
• Accuracy
• Sequence
• Appropriateness
• Completeness
• Conciseness
• Accepted terminology

6. Maintenance Of Computerized
Records:
• Maintain the confidentiality of the information.
• Never disclose the password to any others
• Don’t delete any information from the system
unless you are authorized to do.