Advanced Nursing Practice Toolkit

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Legal and Ethics Guidance

  • Overview
  • What is Ethics?
  • What is Law?
  • Accountability
  • Consent
  • Documentation and Record Keeping
    • Defining a health record
    • Contemporaneous notes
    • Standards of record keeping
    • Systematic record keeping
    • Legal perspectives
    • Access to health records
    • Concept of confidentiality
    • Conclusion and References
    • Case Study Examples
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Conclusion and References

Appropriate record keeping is an integral part of patient care and are important in improving communication and the continuity.  Records are also important for auditing practice and are likely to be central to future complaints, investigations and any subsequent legal action in relation to care delivered to patients.  An awareness of the policies, procedures and frameworks which underpin good record keeping are therefore essential for the advanced practitioner.

References

  • 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
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