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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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Introduction

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. ...read more.

Middle

(Illingworth 2004) For example, patients' record are accessed by different members of the inter-professional health care team. Local protocols respect the patients' right to limit access to certain information about themselves through procedures such as: establish the date and time of any entry and the person who made the entry. This is done through the use of user name and password which identifies the user. There are many legal and professionals issues involved in record keeping. The Nursing and Midwifery Council (NMC 2004) agreed that record keeping is a tool of professional practice which should help the care process delivered by nurses, midwives and specialist community public health nurses. Therefore, good record keeping protects the well-being of patients and clients and enables health care professionals to communicate effectively with patients and other inter-professional health care team in order to ensure the continuity of care. ...read more.

Conclusion

Under the Data Protection Act 1998, patients have the legal right to access their health records whether they were paper-based or computer-held records. The Data Protection Act 1998 also regulates the storage and protection of patient information held on computer. It also allows patients to correct inaccurate information corrected. (NMC, 2005) Furthermore, accordingly to the NMC (2005), there are significant legal and ethical issues concerning the storage and access of patients' records, as records must be kept for a period of eight years or in case of a child, until the child's 21st birthday. In conclusion, there are two types of records in my placement: nursing notes and medical notes, together they deliver a full account of the assessment and the care that has been planned and provided to patients and clients. In order to fulfil the professional and legal duties of care, record keeping should reflect the standards set by the Nursing and Midwifery Council to protect the patients' welfare and to ensure the delivery of high standards of clinical care. ...read more.

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