What are the principles of good documentation and record keeping?
The 8 Principles are: Accountability, Transparency, Integrity, Protection, Compliance, Accessibility, Retention and Disposition. These are the “Principles” of good management of Records.
What are the principles for documentation?
- All documentation. In general, documentation should be…
- Content. “Content” is the conceptual information within documentation.
- Sources. A “source” refers to a system used to store and edit content.
What does the NMC say about record keeping?
The Code of Professional Conduct (NMC, 2002a) advises that good note-taking is a vital tool of communication between nurses. 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.
Why is documentation and record keeping important?
A well-kept record can protect the practitioner in instances where the legal defence of their actions is required. Documentation also ensures a matter of professionalisation and proof of the improvement of practices.
What are the three main types of records?
Types of records
- Correspondence records. Correspondence records may be created inside the office or may be received from outside the office.
- Accounting records. The records relating to financial transactions are known as financial records.
- Legal records.
- Personnel records.
- Progress records.
- Miscellaneous records.
What is the aim of documentation?
The purpose of documentation is to: Describe the use, operation, maintenance, or design of software or hardware through the use of manuals, listings, diagrams, and other hard- or soft-copy written and graphic materials.
What are methods of documentation?
Methods of Documentation
- DAR (data, action, response)
- APIE (assessment, plan, intervention, evaluation)
- SOAP (subjective, objective, assessment, plan) and its derivatives including.
- SOAPIE (subjective, objective, assessment, plan, intervention, evaluation).
What are the different types of documentation?
The four kinds of documentation are:
- learning-oriented tutorials.
- goal-oriented how-to guides.
- understanding-oriented discussions.
- information-oriented reference material.
What is the importance of accurate documentation?
Good documentation is important to protect our programs. Accurate documentation ensures the Federal health care programs pay the right amount—not too much and not too little—to the right people. Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care.
What does the NMC say about documentation?
Key principles All records must be signed, timed and dated if handwritten. If digital, they must be traceable to the person who provided the care that is being documented. Ensure that you are up to date in the use of electronic systems in your place of work, including security, confidentiality and appropriate usage.
What are characteristics of record keeping?
What are the characteristics of record keeping?
- routinely capture records within the scope of the business activity it supports.
- routinely create process metadata.
- provide adequate information about the records within them.
- have controls that will ensure accuracy and quality of records created, captured and managed.
What should be recorded in a real time progress note?
Clinical information that is not recorded within flowsheets and any changes to the plan of care is documented as a real time progress note. Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor perfusion, hypotensive, febrile etc. Change in clinical state, eg.
Which is the best principle for nursing documentation?
11 Nursing Documentation Principles Principle 1. Documentation Characteristics Principle 2. Education and Training Principle 3. Policies and Procedures Principle 4. Protection Systems Principle 5. Documentation Entries Principle 6. Standardized Terminologies 15 Recommendations for Nursing Documentation Practicing Registered Nurses
When do you need a record keeping system?
As a business owner, you should also establish a record keeping system for your personal information. For example, when applying for a business loan, a lender may want to consider your personal records, such as financial statements for your personal checking accounts, savings accounts, and other personal accounts tied to your business.
Why is documentation so important in the RCH?
Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistent clinical communication processes across the RCH.