Professional Documents
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Professionalism in Nursing 4 - Record Keeping, Consent and Capacity
Professionalism in Nursing 4 - Record Keeping, Consent and Capacity
keeping/Legislation
Discussion
Professionalism This article has been
double-blind peer reviewed
In this article...
● H ow to improve patient care through good record keeping and avoid common errors
● The types, validity and legal implications of patient consent
● The importance and complexity of assessing patient capacity
T
participation can implied, informed,
count towards your
revalidation.
verbal or written, his article – the fourth in a series completed after every consultation. Good
and must be on professionalism in nursing – record keeping is an essential professional,
obtained before discusses the importance of good ethical and legal requirement of being a
carrying out care record keeping, acquiring nurse. When completed well, record
patients’ consent and assessing their keeping can promote continuity of care
Mental capacity is an mental capacity. It explores the legal, eth- through clear communication (Davidson
individual’s ability ical and professional implications of these and Devlin, 2012), and can later supply, if
to understand essential parts of nursing. necessary, the evidence for any legal pro-
information and use ceedings. Conversely, poor records may
it to make informed Record keeping in healthcare have a negative effect on care delivery, with
decisions Record keeping is integral to the role of the pertinent information not being docu-
nurse. It is a recurrent theme throughout mented or relayed to the right people.
Legislation states the Nursing and Midwifery Council Several standards listed in the NMC’s
how patients’ mental (NMC)’s (2018) Code, and the importance (2018) Code relate directly to record
capacity should be of good record keeping is reiterated from keeping (Box 1), so adhering to the Code
assessed the beginning of a nurse’s career onwards; when writing documents should ensure
we are all familiar with the saying ‘if it is good record keeping. However, common
not written down, it didn’t happen’. How- errors persist, including:
ever, despite this instruction, poor record ● Confusing facts with opinions;
keeping remains one of the top five rea- ● Using unclear abbreviations;
sons for nurses incurring sanctions or ● Inaccuracies, especially dates and
even being removed from the register times;
(Andrews and St Aubyn, 2015). ● Illegible handwriting;
In a busy, pressurised environment, ● Using Tippex;
record keeping and documentation can ● Omitting times, dates or signatures;
often be seen as a luxury; however, our ● Delays in completing records.
records provide the evidence of our A recent study at a large acute trust
involvement with patients and should be found that patient care information was