RECORD KEEPING

DEFENITION
• Recording is the process of making an entry on a client record.
• The clinical record is a legal document that provides evidence of a
client’s care.
REASONS FOR KEEPING CLIENT’S RECORDS

• Communication
• Planning client care
• Auditing Health agencies
• Research
• Education
• Reimbursement
• Legal documentation
• Health care analysis
• Provides correct account of patient’s treatment and care
Outline the component of the patient’s records
• Patient’s information
• Medical history
• Informed consent form
• Consent form
• Physical examination
• Nurse’s notes
• Physician progress notes
• Laboratory records
Outline the common deficiencies in record keeping
• Absence of clarity
• Significant spelling mistakes
• Failures in communication
• Missing information
Benefits of good record keeping
• Provide correct account of the patient’s treatment and care
• Allows for good communication between colleagues in healthcare team
• Allows nurses to identify problems that have arisen, and the action taken to
rectify them
• Legal significance
General guidelines for Record Keeping
• Date and time
• Timing
• Legibility
• Permanence\
• Accepted terminology
• Correct spelling
• Signatures
• Accuracy
• Sequence
• Appropriateness
• Completeness
• Conciseness
• Legal prudence
METHODS OF KEEPING RECORD
REPORTING
• Communicating specific information to a person or group of
people.
Done during:
- Change of shift
- Telephone reporting and telephone orders
- Sharing information during care plan conference
- Nursing rounds