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, observing the principle of confidentiality means keeping information given by or about an individual in the course of a professional relationship secure and secret from others. This confidentiality is seen as central to the maintenance of trust between professional and service-user. (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.
According to Parkinson and Brooker (2006):''Accurate record keeping and careful documentation is an essential part of nursing practice''. Therefore, good record keeping reflects the standard of the practitioners' professionals practice. There are key factors which contribute to the effectiveness of record keeping. According to NMC (2004), records must be consistent, clear and accurately signed and dated. In addition, records must provide clear information of care planned and delivered as well as decisions made and information shared.
The NMC code of professional conduct (2002) stated, as a registered nurse or midwife, “you must adhere to the laws of the country in which you are practising.” Therefore, NMC (2004) stated that patients' records can be used as evidence in case of claims of negligence and misconduct against health care professionals or be used for criminal proceedings. Therefore, it is the nurses, midwives and specialist community public health nurses' duty to ensure their records demonstrate full account of assessment, care planned and given as well as provide evidence that required steps were taken to care for the patient and any further arrangements made for the continuity of care.
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.
References
-Illingworth, S. (2004) Ethics, The higher education academy [online]. Available from:
<> [Accessed on 20 April 2006]
-Nursing and Midwifery Council (NMC) (2002) Code of professional conduct: protecting the public through professional standards. London: Nursing and Midwifery Council.
-Nursing and Midwifery Council. (2005) Guidelines for records and record keeping. London: NMC
-Nursing and Midwifery Council (NMC) (2004) The NMC code of professional conduct: standards for conduct, performance and ethics. London: NMC
-Parkinson and Brooker (2006). Available from:
[Accessed on 18 March 2006]