Records may differ depending on the needs of the patient or client (NMC 2004). This essay aims to identify different types of records on my placement and discuss their professional and legal implications.

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Records

The Nursing and Midwifery Council believed that “record keeping is an integral part of nursing, midwifery and specialist community public health nursing practice”. However, the NMC accepts that until there is national agreement between health care professions on standards and format, records may differ depending on the needs of the patient or client (NMC 2004). This essay aims to identify different types of records on my placement and discuss their professional and legal implications.

In my practice placement there are two types of records: manual and computer-held records. Manual or paper based records include nurses’ notes and medical notes. The main aim of the nurses’ notes is to record daily observations, evaluations and reviews of patients' condition and progress in order to plan care accordingly. For example, TPR forms (temperature, pulse, BP and respiration), patient assessment and care plan, food and fluid chart, as well as urine and stool chart. However, medical notes include records of symptoms, diagnosis and investigations such as X-rays, films and test results as well as past medical history and referral letters.

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On the other hand, computer held records hold more summarised records of patients which is used by the multidisciplinary team as a tool of communication between them, for example: patients' personal information such as name, address, next of kin contact details, GP details, date and reasons for admission as well as hospital number, date of birth electronic discharge and prescriptions.  

According to The code of professional Conduct (2004), the principle of the confidentiality of information held about patients and clients is as important in computer-held records as in all other records. Within the context of professional ethics, ...

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