Practising as a nurse abroad

Records and Record keeping

Contents Registration UKCC Code of Professional Conduct Accountability Scope of Professional Practice Records and Record Keeping Role and Responsibilities

Record keeping is considered by the UKCC to be a fundamental part of nursing, midwifery and health visiting practice. Documentation and maintenance of medical records thus forms an integral part of care of expedition members. The following information is taken from Guidelines for Records and Record Keeping, UKCC 1998. This document should be referred to for further information.

There is no single model for a record but there are a number of key principles which underpin good records and record keeping. Content and Style, Patient records should:

Be factual, consistent and accurate

Be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient

Be written clearly, accurately and be dated, timed and signed

Not include abbreviations, jargon, meaningless phrases or irrelevant speculation

Be written in terms the patient can easily understand

Legal matters and complaints

Patient records are sometimes called in evidence before a court of law. They may also be used in evidence by the UKCC Professional Conduct Committee, which considers complaints about professional misconduct by registered nurses, midwives and health visitors.

As a registered nurse, midwife or health visitor you have both a professional and a legal duty of care. Your record keeping should therefore be able to demonstrate:

A full account of your assessment and the care you have planned and provided

Relevant information about the condition of the patient at any given time and measures taken to respond to their needs

Evidence that you have understood and honoured your duty of care

Courts of law tend to adopt the approach to record keeping that 'if it is not recorded, it has not been done'. Use your professional judgment to decide what is relevant and what should be recorded.

This may not seem particularly relevant in the middle of the Amazon Rain Forest or a remote African village, but it is important to remember that the UKCC Code of Professional Conduct applies to all UKCC registered nurses wherever in the world they are practising.

Access and ownership

You need to assume that any entries made in a patient record will be scrutinized at some point. Patients have a legal right to see their records, which are usually kept for at least 8 years.

You also have a duty to protect the confidentiality of the patient record.