Records and Record-keeping

• Preface; About the author; Acknowledgements; Common terminology and key concepts1. Health records1.1 Defining health records1.2 The purpose of health records1.2.1 Clinical purposes1.2.2 Non-clinical purposes1.3 Components of a health record2. Management of health records2.1 Confidentiality of health records2.1.1 Definition of confidentiality2.1.2 Confidentiality: an overview of the law2.1.3 Data Protection Act 20182.1.4 Confidentiality and regulation2.2 Ownership of health records2.2.1 NHS employed healthcare practitioners2.2.2 Self-employed healthcare practitioners2.2.3 Non-NHS employed healthcare practitioners2.3 Storage of health records2.3.1 How to store health records2.3.2 Temporary notes2.4 Retention periods2.5 Destruction of health records3. Access to health records3.1 Patients reading their own health records3.2 Accessing health records3.2.1 Patients3.2.2 Relatives3.2.3 Healthcare practitioners3.2.4 Administrative staff3.2.5 Police3.2.6 Own health records3.3 Child patients and access to health records3.3.1 The child patient3.3.2 Individuals exercising parental responsibility3.4 Accessing health records after the death of a patient3.5 Concerns about providing access to a patient's health record4. The standard for record-keeping4.1 A standard for maintaining health records4.1.1 Legal4.1.2 Regulatory4.1.3 Employer4.1.4 Combined approach4.2 Features of good record-keeping5. Practical aspects of health records5.1 Considerations when writing an entry in a health record5.1.1 The right record5.1.2 Signing and initialling entries5.1.3 Language and style of entry5.1.4 Personalised entries5.1.5 Ink colour5.1.6 Referring to other parts of the health record5.1.7 Jargon and abbreviations5.1.8 Electronic communications5.2 Time pressures5.3 Writing entries for colleagues5.4 Changing an entry in a health record5.5 Third party information6. Best practice in record-keeping6.1 Best practice pointers6.2 A process for best practice6.3 My top tip for best practice in record-keepingReferences; Useful resources; Notes

Records and Record-keeping addresses all aspects of record keeping and documentation that student nurses need to know. The links to record keeping for child patients, the NMC code, data protection Act and process of accurate record keeping provides a very informative and concise reference for users.