Advanced Nursing Practice Toolkit

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NHS Scotland
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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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Systematic record keeping

Some health boards have developed policy documents in clinical documentation and some organisations have developed their own electronic templates for patient records facilitating standardised record keeping by advanced practitioners and other members of the multidisciplinary team.  For example the electronic documentation systems used by NHS 24, NHS Direct and Ambulance Services to document care provided by staff within unscheduled care centres and linked to patient emergency care summaries completed by the G.P.

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