Records and Record-keeping: A Pocket Guide for Nursing and Health Care

By Marc Cornock

Effective record-keeping is essential to health care. This book is a handy pocket-sized guide to keeping good health records that treats the process as an integral part of your everyday practice.
Every healthcare practitioner is expected to record their interactions with a patient in the patient’s health record, and this pocket guide is full of practical detail about:

• what a health record is and what its purpose is
• how health records are managed
• who has access to health records
• the importance of maintaining a patient's health record
• best practice in keeping records

Written by an experienced lecturer with input provided by current nursing students, this guidance is produced with you in mind – and you can carry it with you at all times!

• Language: English
• Publisher: Lantern Publishing
• Release date: Mar 3, 2024
• ISBN: 9781914962219

Book preview

Cover: Pocket Guides: Records and Record-keeping by Marc Cornock

A unique series of pocket-sized books designed to help healthcare students

All the information was clear and concise, this book is exactly what I was looking for.

A great little guide. All the basic information needed to have a quick reference.

A very useful, well-written and practical pocket book.

Written by students for students. A must for any student about to head on placement.

Logo: Lantern Publishing Ltd

ISBN 9781914962202

First published in 2024 by Lantern Publishing Ltd

Lantern Publishing Limited, The Old Hayloft, Vantage Business Park, Bloxham Road, Banbury OX16 9UX, UK

www.lanternpublishing.com

© 2024, Marc Cornock. The right of Marc Cornock to be identified as author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, copied or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without either written permission from Lantern Publishing Ltd or by a licence permitting restricted copying in the UK issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS, UK.

www.cla.co.uk

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

The authors and publisher have made every attempt to ensure the content of this book is up to date and accurate. However, healthcare knowledge and information is changing all the time so the reader is advised to double-check any information in this text on drug usage, treatment procedures, the use of equipment, etc. to confirm that it complies with the latest safety recommendations, standards of practice and legislation, as well as local Trust policies and procedures. Students are advised to check with their tutor and/or practice supervisor before carrying out any of the procedures in this textbook.

Typeset by Medlar Publishing Solutions Pvt Ltd, India

Printed and bound in the UK

Last digit is the print number: 10 9 8 7 6 5 4 3 2 1

Contents

Preface

About the author

Acknowledgements

Common terminology and key concepts

1.Health records

1.1Defining health records

1.2The purpose of health records

1.2.1Clinical purposes

1.2.2Non-clinical purposes

1.3Components of a health record

2.Management of health records

2.1Confidentiality of health records

2.1.1Definition of confidentiality

2.1.2Confidentiality: an overview of the law

2.1.3Data Protection Act 2018

2.1.4Confidentiality and regulation

2.2Ownership of health records

2.2.1NHS employed healthcare practitioners

2.2.2Self-employed healthcare practitioners

2.2.3Non-NHS employed healthcare practitioners

2.3Storage of health records

2.3.1How to store health records

2.3.2Temporary notes

2.4Retention periods

2.5Destruction of health records

3.Access to health records

3.1Patients reading their own health records

3.2Accessing health records

3.2.1Patients

3.2.2Relatives

3.2.3Healthcare practitioners

3.2.4Administrative staff

3.2.5Police

3.2.6Own health records

3.3Child patients and access to health records

3.3.1The child patient

3.3.2Individuals exercising parental responsibility

3.4Accessing health records after the death of a patient

3.5Concerns about providing access to a patient’s health record

4.The standard for record-keeping

4.1A standard for maintaining health records

4.1.1Legal

4.1.2Regulatory

4.1.3Employer

4.1.4Combined approach

4.2Features of good record-keeping

5.Practical aspects of health records

5.1Considerations when writing an entry in a health record

5.1.1The right record

5.1.2Signing and initialling entries

5.1.3Language and style of entry

5.1.4Personalised entries

5.1.5Ink colour

5.1.6Referring to other parts of the health record

5.1.7Jargon and abbreviations

5.1.8Electronic communications

5.2Time pressures

5.3Writing entries for colleagues

5.4Changing an entry in a health record

5.5Third party information

6.Best practice in record-keeping

6.1Best practice pointers

6.2A process for best practice

6.3My top tip for best practice in record-keeping

References

Useful resources

Dedication

For Karin and Simon, two of the best.

To find one good friend in a lifetime is an achievement, to find two like you two is beyond expectations and words.

A good health record entry allows someone to reconstruct what happened, years after the event, without recourse to memory.

This was said to me by a doctor many years ago when I was young and naive and