Record keeping

There are many reasons for keeping records in health care, but two stand out above all others:

  • to compile a complete record of the patient’s/client’s journey through services
  • to enable continuity of care for the patient/client both within and between services.

The records we keep in health care need to be clear, accurate, honest and timely (meaning they should be written as near as possible to the actual time of occurrence of the events they describe).

Different means of record-keeping are used in health care settings. Some workplaces use hand-written records, others have moved to computer-based systems, and many use a combination of both. You’ll be expected to be able to comply with whatever requirements your employer sets for record-keeping, be it hand-written or electronic. That means you’ll need to:

  • know how to use the information systems and tools in your workplace
  • protect, and do not share with anyone, any passwords or ‘Smartcards’ given to you to enable you to access systems
  • make sure written records are not left in public places where unauthorised people might see them, and that any electronic system is protected before you sign out.

There are principles of record-keeping that we will look at in this section, chief among which is the need to protect patients/clients confidentiality. The RCN has provided some guidance on record keeping called `Delegating record keeping and countersigning records’.

But before we begin to explore these principles, we should be aware that apart from being clear, accurate, honest and timely about what we write, we also need to be careful. This means we have to ensure that nothing we write is, or could be interpreted as being:

  • insulting or abusive
  • prejudiced
  • racist, sexist, ageist or discriminatory in any way.

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