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When, how and why to make patient records

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Article:

Ensuring best practice in clinical record-keeping

 

THIS ARTICLE WILL TELL YOU ABOUT

  • Why record-keeping is important
  • How records are used to investigate incidents
  • Your own accountability

YOU WOULD BE LIKELY TO REFERENCE THIS ARTICLE IF YOU WERE RESEARCHING:

Record-keeping in healthcare or how investigations into care are carried out.

IN WHAT SITUATIONS WILL THIS ARTICLE BE USEFUL FOR ME?

This article would be useful for all student nurses as all nurses need to understand and appreciate the importance of clear and accurate documentation.

 

QUESTIONS FOR YOUR MENTOR/TUTOR

How do you ensure you have made a note of everything you need to during busy shifts?

What information should I always record?

STUDENT NT DECODER

Litigation
The process of taking a case through court.

Negligence
In healthcare this refers to a failure to give care to a standard that is reasonably expected, either through actions or omissions.

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