1. Maintaining best practice in record-keeping and documentation.
- Author
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Beach, Jane and Oates, Jennifer
- Subjects
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INFORMATION resources -- Law & legislation , *DOCUMENTATION , *HEALTH , *INTERPROFESSIONAL relations , *MEDICAL personnel , *NURSING practice , *PATIENTS , *ELECTRONIC health records , *INFORMATION resources , *LAW - Abstract
This article considers best practice in record-keeping and documentation in the light of recent public inquiries and reports, renewed national interest in record-keeping standards, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. The nature of the nurse-patient relationship is also changing, and should be reflected in nurses' record-keeping practices. Collaborative approaches to the planning and evaluation of care, and more emphasis on patients having a greater sense of ownership of information held about them should be reflected in nurses' and other healthcare professionals' attitudes and approaches to this aspect of practice. [ABSTRACT FROM AUTHOR]
- Published
- 2014
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