Principles of record-keeping.
The overall principles of record-keeping, whether you are writing by hand or making entries to electronic systems, can be summed up by saying that anything you write or enter must be honest, accurate and non-offensive and must not breach patient confidentiality.18 Apr 2015
What is meant by record keeping discuss the significance and principles of record keeping?
recordkeeping system. Systematic procedure by which the records of an organization are created, captured, maintained, and disposed of. This system also ensures their preservation for evidential purposes, accurate and efficient updating, timely availability, and control of access to the them only by authorized personnel
What is good record keeping?
It states that nurses ‘must ensure that the health care record for the patient or client is an accurate account of treatment, care planning and delivery. It should be written with the involvement of the patient or client wherever practicable and completed as soon as possible after an event has occurred.14 Jan 2003
What are the three main types of records in care?
Components of a patient’s records include:
- Medical records.
- Nursing records/progress notes.
- Medication charts.
- Laboratory orders and reports.
- Vital signs observation charts.
- Handover sheets and admission.
- Discharge and transfer checklists/ letters.
- Patient’s assessment forms, such as nutrition or pressure area care assessment.
27 May 2018
Why is good record keeping important?
Keeping good records is vital for any business. Whether that’s to help manage your costs, whether it’s for legal, regulatory or tax reasons, or simply to help manage and improve your business. Collecting, storing and effectively analysing your data is vital.8 Dec 2016