Documentation and Record Keeping
Resources
NMC Guidance on Record Keeping
NHSScotland Code of Practice on Protecting Patient Confidentiality
Access to Health Records Act 1990
Audit Commission, 1999. Setting the Record Straight: A Review of Progress in Health Records Services London: The Stationary Office
Data Protection Act 1998
Freedom of information (Scotland) Act 2002
Gaskin V UK (1990) 1 FLR 167
Griffiths, R. Tengnah, C., 2010. Law and Professional Issues in Nursing. (2nd Ed). Padstow : Learning Matters Limited
Health Records Act 1998
Kent v Griffiths and others (2000) 3 CLL Rep 98
Nursing and Midwifery Council, 2002. Coventry Nurse struck off for Filing to keep Proper records (NMC Press Statement 224/20 London: NMC
Nursing and Midwifery Council, 2009. Record Keeping: Guidance for Nurses and Midwives. London: NMC
Prendergast v Sam and Dee (1989) 1 Med LR 36
Case studies exploring the following ethical and legal issues in clinical practice can be found on the UK Clinical Ethics Network website:
- Who should get an intensive care bed?
- A competent patient refuses treatment
- Breaching confidentiality to protect others.
Key legal and ethical issues are highlighted in the following short video clips provided on the Ministry of Ethics website.
- Police & RTA Consent (consent, incapacity)
- Non-Accidental Injury (Child protection, breach of confidentiality in public interest)
- HIV Part 1 (Informed consent, confidentiality and breach in public interest, duty of care)
- Blood transfusion (consent, confidentiality, incapacity)
- Needlestick Injury (consent, confidentiality, incapacity)
- 14 year old and contraception (consent, confidentiality)
- Dealing with authorities (confidentiality and breach of confidentiality).
