Documentation and Record Keeping
The Nursing and Midwifery Council (2009) highlight good record keeping as an integral part of practice and essential to the provision of safe and effective care. They acknowledge that good record keeping has a range of important functions including, improving communication between healthcare professionals, supporting delivery and continuity of patient care, demonstrating clinical judgements and decision making and identifying risk for patients. See NMC guidance on record keeping for more information.
Patient health records also have a function in improving accountability and in so doing have a legal purpose in providing evidence of the practitioners' involvement or interventions in relation to patients or clients. The following information is applicable to all nurses and midwives with some aspects having particular relevance to the advanced practitioner.
