Nursing & Health Survival Guide : Record Keeping.
By: Lillyman, Susan.
Contributor(s): Merrix, Pauline.Material type: TextSeries: eBooks on Demand.Nursing and Health Survival Guides: Publisher: Welwyn Garden City : Taylor and Francis, 2014Copyright date: ©2011Description: 1 online resource (42 pages).Content type: text Media type: computer Carrier type: online resourceISBN: 9781317905813.Subject(s): Nursing records -- Handbooks, manuals, etcGenre/Form: Electronic books.Additional physical formats: Print version:: Nursing & Health Survival Guide: Record KeepingDDC classification: 610.73 Online resources: Click here to view this ebook.
|Item type||Current location||Call number||URL||Status||Date due||Barcode|
|Electronic Book||UT Tyler Online Online||RT50 -- .M477 2014 (Browse shelf)||http://ebookcentral.proquest.com/lib/uttyler/detail.action?docID=1782376||Available||EBC1782376|
Cover -- Title -- Copyright -- contents -- INTRODUCTION -- RECORDS -- Why are records needed? -- Types of records -- What makes a good record? -- What makes a poor record? -- Recording professional judgements -- Being objective in your records -- Using abbreviations -- How to amend entries if needed -- Electronic records -- Storage of records -- Patient held records -- Destruction of records -- ACCESS TO RECORDS -- For the patient -- To solicitors -- To the court -- To the police -- To the media -- For research -- For a student -- After death -- PREPARING FOR THE LEGAL DEFENSIBILITY OF RECORD KEEPING -- CONFIDENTIALITY -- In records or conversations -- For course work -- The Caldicott Report -- Caldicott key principles -- Disclosure -- Consent to disclose -- CONSENT TO TREATMENT AND RECORD KEEPING -- How to assess competence/capacity -- What to record in the health records concerning consent -- Children and consent -- Loss of capacity -- Consent: Disability Discrimination Act -- Right to withdraw/refuse consent -- ETHICS, ACCOUNTABILITY AND RECORD KEEPING -- MAINTAINING YOUR SKILLS FOR RECORD KEEPING -- RELEVANT LEGISLATION -- OTHER RECORDS -- Patient's advance statement -- Advance decision -- Personal professional records -- CONCLUSION -- Scenarios 1-3: demonstrating public interest disclosure -- Scenario 4: demonstrating record keeping with child consent -- KEY REFERENCES -- USEFUL WEBSITES.
Effective record keeping is a sign of safe and skilled Nurses and Midwives and is a legal requirement for all Healthcare professionals. This pocket-sized guide provides you with the tools to write clear and concise records. The Nursing & Health Survival Guides have evolved - take a look at our our app for iPhone and iPad.
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