Essentials of Nursing Practice
Chapter 18: Record-keeping and documentation
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www.bris.ac.uk/cipold.
Poor record-keeping has also been a factor in many recent adult abuse inquiries; this report identifies many lapses in accurate record-keeping. -
www.rcn.org.uk/development/health_care_support_workers/professional_issues/accountability_and_delegation_film
As a nursing student, you must take personal accountability for accurate record-keeping. You must be supervised in this activity and all of your entries must be counter-signed by a registered nurse until such time as your mentor deems you competent. -
www.cqc.org.uk.
The Care Quality Commission’s recent Mental Health Act Annual Report highlighted that some patients were not involved in care planning and had no idea what was in their care plan. -
www.nmc.org.uk/standards/code/record-keeping/
Nursing & Midwifery Council – advice on record keeping. -
www.rcn.org.uk/get-help/rcn-advice/record-keeping
Royal College of Nursing – advice on record keeping.