Maintaining best practice in record-keeping and documentation

Abstract

This article considers best practice in record-keeping and documentation in the light of recent public inquiries and reports, renewed national interest in record-keeping standards, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. The nature of the nurse-patient relationship is also changing, and should be reflected in nurses' record-keeping practices. Collaborative approaches to the planning and evaluation of care, and more emphasis on patients having a greater sense of ownership of information held about them should be reflected in nurses' and other healthcare professionals' attitudes and approaches to this aspect of practice.

Full text

© NURSING STANDARD / RCN PUBLISHING may 7 :: vol 28 no 36 :: 2014 45
CONTINUING
PROFESSIONAL
DEVELOPMENT
CPD
Aims and intended learning outcomes
This article aims to set the nursing practice of
record-keeping in the context of recent public
inquiries and guidance, as well as current policy
and legislation. It discusses the risks, challenges
and opportunities of electronic record-keeping.
It also considers record-keeping in the context
of collaborative working with patients, service
users and colleagues from other professions.
After reading this article and completing the
time out activities you should be able to:
Describe the principles of good information
governance.
Discuss recent developments in information
governance policy and practice.
Review the quality of your patients’
clinical records.
Assess the quality of your patients’
care plans.
Identify sources of further information
and guidance on record-keeping.
Introduction
Health records provide evidence about the
care and treatment patients receive. They
include progress notes, assessments and care
plans, as well as letters written to and about
patients, and written communication between
colleagues about patients. Health records
are not only evidence of care, they are also
clinical tools, enabling continuity of care and
appropriate decision making about future
care and treatment. If the quality of care
provided is called into question, then health
records and documents will be essential to any
investigation or review. From a governance
and commissioning perspective, health records
 Page 52
Record-keeping multiple
choice questionnaire
 Page 53
Read Michael Danthis’
practice profile on
whooping cough
 Page 54
Guidelines on
how to write a
practice profile
Maintaining best practice in
record-keeping and documentation
NS742 Beach J, Oates J (2014) Maintaining best practice in record-keeping and documentation.
Nursing Standard. 28, 36, 45-50. Date of submission: February 5 2014; date of acceptance: March 10 2014.
Abstract
This article considers best practice in record-keeping and documentation
in the light of recen t public inquiries and repor ts, renewe d national interest
in record -kee ping sta ndards , and the cha llenge of moving fro m paper
to elec tronic healthcare document ation and digital storage of data. The
nature of the nurse-patient relationship is also changing, and should be
reflected in nurse s’ record- ke ep in g practices. Collaborative approaches to
the planning and evaluation of care, and more emphasis on patients having
a greater sense of owne rshi p of information held about them should be
reflected in nurses’ and other healthcare professionals’ attitudes and
approaches to this aspect of practice.
Authors
Jane Beac h
Professional officer for regulation, Unite/Community Practitioners and
Health Visitors Association, West Bromwich.
Jennifer Oates
Freelance regulatory policy and resea rch consultant , Brighton.
Correspondence to: Jane.Beach@unitetheunion.org
Keywords
Confidentiality, documentation, information governance,
professional issues, record-keeping, regulation
Review
All artic le s are subject to external double -blind pee r review and che cked
for plagiarism using automated software.
Online
Guideline s on writin g for pub lication are ava ilable at
www.nursing-standard.co.uk. For related articles visit the archive and
search using the keywor ds above.
045-050w36 CPD.indd 45 02/05/2014 11:58
Downloaded from RCNi.com by ${individualUser.displayName} on Mar 06, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCNi Ltd. All rights reserved.

46 may 7 :: vol 28 no 36 :: 2014 © NURSING STANDARD / RCN PUBLISHING
CPD professional issues
provide evidence that care is meeting quality
and safety standards set and monitored by
regulators and also the contractual requirements
set by commissioners (Unite the Union
2014). The NHS code of practice for records
management states that: ‘All individuals who
work for an NHS organisation are responsible
for any records which they create or use in the
performance of their duties’ (Department of
Health (DH) 2006).
Complete time out activity 1
Inuences on record-keeping
The quality of clinical records has been
discussed in several recent serious case reviews
and public inquiries. The reviews of N HS
complaints (Clywd and Hart 2013) and of the
Liverpool Care Pathway (Neuberger 2013) drew
attention to deficiencies and difficulties faced
by NHS staff in documenting care accurately.
The reviews of care at University Hospitals of
Morecambe Bay NHS Foundation Trust (Care
Quality Commission (CQC) 2012) and Mid
Staffordshire NHS Foundation Trust (Mid
Staffordshire NHS Foundation Trust Inquiry
2010, Francis 2013) included critiques of
record-keeping practices. The latter found poor
quality record-keeping, ‘observed too frequently
to be attributable to isolated poor practice on
the part of individuals’ (Mid Staffordshire
NHS Foundation Trust Inquiry 2010), in the
form of incomplete and inconsistent records,
inaccurate recording of patient information and
discussions with patients and families, and poor
recording of transfer information. Interviews
with families described lapses in information
security and concerns regarding the accuracy
of records about those receiving care. The Mid
Staffordshire NHS Foundation Trust Inquiry
(2010) recommended that: ‘Accurate and
thorough record keeping is an essential part of
the care to be provided to any patient. Without
it appropriate plans cannot be made or followed
through, changes in condition cannot be
monitored, and continuity of care is prejudiced.’
At University Hospitals of Morecambe
Bay NHS Foundation Trust, the CQC (2012)
found evidence of incomplete records and drew
attention to the effect of poor record-keeping on
delayed discharge of patients and deterioration
of patient health. There were concerns about
how medical records were stored, with staff
stating: ‘There is a culture within the trust
of hoarding notes in small stock piles when
clinical teams know that the patient will return
to them in a number of weeks’ (CQC 2012).
Ward-level solutions to the systemic problem of
being unable to store, locate and retrieve patient
health records, namely the hoarding of notes for
patients likely to re-present, were found to affect
timely treatment and quality of care. The CQC
(2012) recommended that the trust improve
its systems for the management of records to
ensure that notes can be retrieved effectively
and to reduce the risks associated with multiple
temporary sets of notes.
Policy and guidance: recent developments
In addition to concerns about record-keeping
and documentation in recent inquiries,
there have been developments in policy and
guidance on information governance that
potentially affect nursing practice. A Guide
to Confidentiality in Health and Social
Care (Health and Social Care Information
Centre (HSCIC) 2013) offers an up-to-date
account of the duties of health and social
care organisations to handle confidential
information. The HSCIC was given the
statutory authority in the Health and Social
Care Act 2012 to lead on this issue. The newly
formed Professional Record Standards Body
has sanctioned the shared standards for the
content and structure of patient records set
by the Royal College of Physicians and the
Academy of Medical Royal Colleges (HSCIC
and Academy of Medical Royal Colleges
2013). These shared standards apply to
referral letters, inpatient notes, handover
communications, discharge summaries and
outpatient letters, and have been approved by
the Royal College of Nursing, along with other
medical royal colleges who are also members
of the Professional Record Standards Body.
One of the most significant developments
in terms of guidance, is the publication of
Dame Fiona Caldicott’s second information
governance review (DH 2013a). This review
considered the effect of the recommendations
of the first review, namely the adoption of the
six Caldicott principles and the establishment
of the Caldicott Guardian role (DH 1997). The
original Caldicott principles set out expectations
of how personal-identi fiable information should
be used and shared. The Caldicott Guardian
is a nominated senior individual in each NHS
organisation who oversees the use and sharing
of personal-identifiable information. While
acknowledging the challenges faced in
implementing the original Caldicott principles,
the second review added a seventh principle
(DH 2013a): ‘The duty to share information
can be as important as the duty to protect
1 List the guidance,
policies and legislation
that affect how you
create and use health
records. Once you
have completed this
article, return to this
list and add any further
guidance, policies and
legislation of which you
are now aware.
Join our First Friday
Twitter discussion
about issu es raised
in this article.
Friday June 6
from 12. 30-1.30
using #NursingJC
Journal
Club
#NursingJC
Journal
Club
#NursingJC
045-050w36 CPD.indd 46 02/05/2014 11:58
Downloaded from RCNi.com by ${individualUser.displayName} on Mar 06, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCNi Ltd. All rights reserved.

© NURSING STANDARD / RCN PUBLISHING may 7 :: vol 28 no 36 :: 2014 47
patient confidentiality. Health and social care
professionals should have the confidence to
share information in the best interests of their
patients within the framework set out by
these principles’. Box 1 lists the seven
Caldicott principles.
Complete time out activity 2
Legal, professional and regulatory inuences
Broadly speaking, nurses’ record-keeping
practice should reflect an understanding of
the relevant legislation and regulations,
as well as national and local policy. Local
NHS policies should reflect the national
NHS policies on information governance,
confidentiality, information security, records
management and the NHS constitution (DH
2003, 2006, 2007, 2013b). At an employer
level, there is a duty that all employees,
including nurses, are made aware of their
responsibilities under the Data Protection
Act 1998 and Freedom of Information Act
2000. Activity pertaining to these two acts is
overseen by the Information Commissioner’s
Office (www.ico.org.uk).
Nurses working in regulated care settings
should abide by standards set by the relevant
regulator. For example, in England, care is
regulated by the CQC under the Health and
Social Care Act 2008 (Regulated Activities)
Regulations 2010, and nurses should be
particularly aware of the stipulations of
Regulation 20 (Box 2).
All nurses are bound by what The Code
(Nursing and Midwifery Council (NMC)
2008) says about record-keeping (Box 3).
‘Failure to maintain adequate records’ is a
regularly cited allegation in ‘fitness to practise’
cases (NMC 2011). It often comes to light as
a secondary concern, when potential cases of
lack of competence and misconduct are being
investigated. Many of the broad themes of
The Code have a bearing on nurses’
record-keeping, including working with
others, respecting people’s rights, upholding
the laws of the land, and providing care that
is safe and of a high standard. The Code also
sets out the nurse’s responsibilities regarding
confidentiality, consent and information
sharing. It is worth noting that The Code
is subject to a review and is expected to be
revised imminently. However, these thematic
concerns are likely to remain in some form.
It is also worth referring to the specific NMC
(2009) guidance on record-keeping, although
this does not have the same status and legal
effect as The Code.
Electronic records and information
governance
The move towards electronic versus paper
records has the potential to enhance
multiprofessional working, particularly in the
way that primary and secondary care services
interact. T he Summary Care Record – an
electronic record of patients’ details relating
to allergies, current prescriptions and adverse
reactions to medicines – and equivalents are
being introduced in the UK, enabling emergency
services to access important information about
patients, regardless of their location. This should
enable a more integrated approach to care, and
improved patient access to and ownership of
personal information. However, it is important
that standards and policy take into account this
new way of working.
The main areas of concern for nurses in
relation to information governance are consent,
information sharing and confidentiality. The
purpose of information governance is to establish
the policies and structures that regulate how data
are processed to provide assurance about how
2 Who is the Caldicott
Guardian in your
organisation? How is
that person contacted?
BOX 1
Caldicott principles
1. Justify the purpose(s).
2. Don’t use personal confidential data unless it is absolutely necessary.
3. Use the minimum necessary personal confidential data.
4. Access to personal confidential data should be on a strict need-to-know basis.
5. Everyone with access to personal confidential data should be aware of
their responsibilities.
6. Comply with the law.
7. The duty to share information can be as important as the duty to protect
patient confidentiality.
(Depar tment of Health 201 3a)
BOX 2
Regulation 20 of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2010
Records
1. The registered person must ensure that service users are protected against
the risks of unsafe or inappropriate care and treatment arising from a lack
of proper information about them by means of the maintenance of:
(a) an accurate record in respect of each service user, which shall include
appropriate information and documents in relation to the care and
treatment provided to each service user; and
(b) such other records as are appropriate in relation to:
(i) persons employed for the purposes of carrying on the regulated activity; and
(ii) the management of the regulated activity.
2. The registered person must ensure that the records referred to in
paragraph 1, which may be in paper or electronic form, are:
(a) kept securely and can be located promptly when required;
(b) retained for an appropriate period of time; and
(c) securely destroyed when it is appropriate to do so.
045-050w36 CPD.indd 47 02/05/2014 11:58
Downloaded from RCNi.com by ${individualUser.displayName} on Mar 06, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCNi Ltd. All rights reserved.

48 may 7 :: vol 28 no 36 :: 2014 © NURSING STANDARD / RCN PUBLISHING
CPD professional issues
organisations are managing personal-identifiable
information. Such policies must take account of
the risks and opportunities inherent in digital
health records and electronic communication.
This is particularly important because:
Written information can be shared with
colleagues in other services at the touch
of a button.
Written information can be shared with
several colleagues at once.
A digital trail indicates who accessed
information and when.
There is the possibility of accessing the
health records of people for whom one is not
providing direct care.
These issues were addressed in Caldicott’s
review in 2013 (DH 2013a) and advice on how
to handle confidential information securely was
issued to organisations by the HSCIC (2013).
Individual practitioners are also accountable
for ensuring confidential information is
handled appropriately, and this includes:
Not sharing passwords.
Not leaving confidential documentation
unattended.
Logging out of computers following use.
Keeping con fidential and personal-identifiable
information in locked storage.
Ensuring consent to share information is
given and people know what information
about them is being kept and with whom it
is shared.
Disclosing personal information only to
people who have a legitimate need for it.
Ensuring all records kept follow standards
of accuracy.
Complying with the law and local
policies about information sharing and
data handling.
Using data only for the purpose for which
it was given.
Equally, practitioners have a responsibility to
ensure colleagues also adhere to these principles.
How to write records
There are numerous uses for and potential
readers of health records. Whatever those
uses and whoever those readers, the primary
aim is to communicate accurately any
observations, actions and discussions relevant
to the patient or service user. With a move
towards collaborative and shared approaches
to care, both with colleagues from other
disciplines and patients, nurses need to
adopt a style of writing that suits this way
of working. This means that health records
should be understood by prospective readers
who may not have the specific professional
knowledge of the person writing the
health record.
The use of archaic terms, acronyms,
abbreviations or professional jargon may
confuse and unnecessarily complicate
communication, particularly for lay readers.
One of the strengths of electronic health
records is that it is removed from the days
of healthcare professionals scribbling
illegibly in patient notes, using terms and
shorthand that only they or those with their
professional background could understand.
It is a good discipline to write health records
as if the patient might request to read them or
professionals may be asked to rely on them
as evidence in a court of law. This approach
should encourage brevity and a focus on facts
rather than opinions.
The standards promoted by the Professional
Record Standards Body (HSCIC and Academy
of Medical Royal Colleges 2013) go some way
to assist collaborative working through defining
content and structure of patient records.
Whether these standards are adopted in the
professional’s organisation or not, he or she
will be constrained by the structures used in
whatever electronic system or paper pro formas
the organisation adopts. The professional does,
however, have scope in the written language
used to assist readers and him or herself at a
later date.
Orwell (1962) discussed the use of written
English to express ideas clearly and succinctly,
suggesting the need to:
Write in short sentences.
Use simple short words.
Avoid using jargon or abbreviations.
Stick to the facts.
Complete time out activity 3
3 Look at recent
entries in the case
notes of one of your
patients. Do they follow
the guidance in this
article on how to write
records? If not, analyse
how those entries could
have been written
to make them more
succinct and precise.
BOX 3
Record-keeping in The Code
Keep clear and accurate records
42. You must keep clear and accurate records of the discussions you have,
the assessments you make, the treatment and medicines you give, and
how effective these have been.
43. You must complete records as soon as possible after an event has occurred.
44. You must not tamper with original records in any way.
45. You must ensure any entries you make in someone’s paper records are
clearly and legibly signed, dated and timed.
46. You must ensure any entries you make in someone’s electronic records
are clearly attributable to you.
47. You must ensure all records are kept securely.
(Nursing and Midwifery Council 2008)
045-050w36 CPD.indd 48 02/05/2014 11:58
Downloaded from RCNi.com by ${individualUser.displayName} on Mar 06, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCNi Ltd. All rights reserved.

© NURSING STANDARD / RCN PUBLISHING may 7 :: vol 28 no 36 :: 2014 49
Writing for colleagues
Nurses may be aware of the principles of good
record-keeping while struggling to put them
into practice. Time constraints and workload
can often affect how nurses prioritise this aspect
of care. However, the recording of care is not a
distinct activity from delivering care, and time
should be allocated for documentation as part
of the patient contact.
NMC (2009) guidance on record-keeping
states: ‘You should record details of any
assessments and reviews undertaken, and
provide clear evidence of the arrangements
you have made for future and ongoing care.
This should also include details of information
given about care and treatment’. Also, ‘records
should identify any risks or problems that have
arisen and show the action taken to deal with
them’ (NMC 2009). This implies that where
risks and safety issues have been identified,
nurses have a duty to ensure they are being
addressed. Putting Patients First. The Duty of
Care (Public World and Unite the Union 2014)
provides further clarification of how healthcare
professionals can interpret their duty of care.
Increasing numbers of patients and
service users have complex, multiple needs.
Multiprofessional working is, therefore, essential
to provide integrated care (Royal College of
Physicians 2011), and this requires an increased
focus on all aspects of record-keeping. In July
2013, the HSCIC and Academy of Medical
Royal Colleges published standards for the
clinical structure and content of patient records,
including referral let ters, inpatient clerking,
handover communications, discharge summaries
and outpatient letters. T hey set out the generic
headings under which patient information
should be writ ten and what should be recorded
under each heading.
Nurses communicate with colleagues about
the care of their patients through care plans
and progress notes. The aim of a care plan is to
enable the team providing care, as well as the
author of the plan, to meet the assessed needs
or goals of the person receiving care. The care
plan needs to be current, accurate and evidence
based, with SMART (specific, measurable,
achievable, realistic and timed) objectives.
In addition to a care plan, there needs to be
a written record of the direct care provided.
This will usually be in the form of progress or
case notes, which may be paper or electronic.
A well constructed care plan should enable all
those involved in the person’s care to write good
quality progress notes. It is essential that these
notes follow good record-keeping practice and
reflect lawful, person-centred care. They should
be explicitly linked to the individual’s care plan.
The move to electronic records has led, in some
organisations, to the use of generic plans. This
approach is not in keeping with the ethos of
shared care planning with patients and service
users. Efforts must be made to reflect the current
expectation of individualisation, personalisation
and collaboration in care plans, given the effect
that a plan can have on subsequent care provided
by other team members.
Complete time out activity 4
Writing for patients and service users
Patients and service users are increasingly being
encouraged to become involved in decisions
about their health and care. This cultural change
is reflected in the U K government’s health
information strategy (DH 2012), arising from
the ‘no decision about me without me’ approach
(DH 2010). Consequently, there is a shift towards
patients having access to the information that
is held about them rather than healthcare
professionals being in sole control. By 2015 in
England, GP practices will be expected to offer
patients access to online services, communication
with the practice and personal records (Royal
College of General Practitioners (RCGP) 2013).
This has been piloted with patients who have
long-term conditions, and along with the
Summary Care Record, is considered to be of
benefit to patients by increasing their ownership
of their illness and information held about them
(NHS 2011, RCGP 2013).
This means that information held about
people primarily belongs to them (DH 2012).
Better access to health records and this
shift in culture in relation to ownership, is
considered to be a way of improving quality
of care (NHS England 2014). However,
concern that patient access and ownership
presents potential risks in relation to
confidentiality and data sharing has meant
that the proposed data sharing initiative has
recently been stalled (Cooper 2014).
Patient representation groups have called
for increased assurance about the safety and
privacy of patient information. With such
debates taking place, patients will expect
healthcare professionals to be able to explain
and discuss information governance with them,
as well as assuming they are adhering to it in
their practice. Consequently, documentation
should demonstrate good record-keeping
practice in terms of what is written and how
such information is stored and shared.
Complete time out activity 5
4 Look at a recent
care plan you have
written or one you have
followed for a patient.
Does the care plan
reflect the individual’s
needs? Does it contain
information that is
accurate and evidence
based? Does the care
plan use SMART
objectives? Did the
care plan enable you or
members of your team
to meet the patient’s
assessed needs or goals?
5 Outline the main
points you would make
when discussing with
patients the advantages
and disadvantages of
sharing data from their
health records as part of
the NHS England (2014)
Better Information
Means Better Care
initiative.
045-050w36 CPD.indd 49 02/05/2014 11:58
Downloaded from RCNi.com by ${individualUser.displayName} on Mar 06, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCNi Ltd. All rights reserved.

50 may 7 :: vol 28 no 36 :: 2014 © NURSING STANDARD / RCN PUBLISHING
CPD professional issues
Writing for a par ticular service
The information contained in health records
has uses beyond direct care. It may be used
as part of quality and risk monitoring, for
example to inform hospital episode statistics
or secondary uses service data; for public
health, research and audit purposes; or for
commissioning and financial decisions. It
may also be used by the system regulators,
for example the CQC in England, or its
equivalents elsewhere in the U K – or by
professional regulators as part of their
investigations. Therefore, the quality of
health records may have an effect on the
healthcare professional, his or her colleagues
and the public in the future.
From 2014, the HSCIC in England
will be publishing all nationally held
clinical data, by clinical team where
possible (DH 2012). Data will increasingly
be used to monitor service performance
and enable comparisons to be made. This
means that there will be publicly available
information about how specific teams
are working.
Conclusion
Health records should demonstrate good
patient care. There is a range of legislation,
policy and guidance that should determine
what nurses write about and how they share
and store that information. When creating
health records, nurses should be aware of
the wider audience and uses of their records.
Information governance practices should
take account of the various approaches to
electronic record-keeping, and the particular
risks and opportunities associated with this
way of working. It is worth bearing this
wider perspective in mind when negotiating
for and allocating time in the working day
for maintenance of documentation. It is in
everyone’s best interests for this activity to be
seen as a vital aspect of clinical practice NS
Complete time out activity 6
References
Care Quality Commission (2012)
Investigation Repor t. University
Hospitals of Morecambe Bay NHS
Foundation Trust. CQC, London.
Clwyd A, Ha rt T (2013) A Review
of the NHS Hospita ls Complaints
System: Putting Patients B ack in the
Picture. Final Repor t. The Stat ionery
Office, Londo n.
Cooper C (2014) Victory for Privacy
as NHS Database is Delayed. tinyurl.
com/o4y3s8 8 (Last accessed:
April 15 2014).
Depar tment of Health (1997) The
Caldicot t Committe e Report on
the Review of Patient-Identifiable
Information. The Stationery Office,
London.
Depar tment of Health (2003)
Confidentiality: NHS Code of Practic e.
The Statio nery Of fice, London.
Depar tment of Health (200 6)
Records Ma nagement: NHS Code
of Practice. Part 1. The Stationer y
Office, Londo n.
Depar tment of Health (2007 )
NHS Information Governance:
Guidance on Legal and Professional
Obligations. The Stationery Office,
London.
Depar tment of Health (2010) Equity
and Excellence: Liberating the NHS.
The Stationery O ffice , London .
Depar tment of Health (2012) The
Power of Information: Putting All
of Us in Control of the Health and
Care Informa tion We Need. The
Stationery Of fice, London.
Depar tment of Health (2013a)
Informatio n: To Share or Not to
Share. Th e Information Governance
Review. The Statione ry Of fice,
London.
Depar tment of Health (2013b)
The NHS Constitution for England.
The Stationery O ffice , London .
Francis R (2013) Report of the Mid
Staffordshire NHS Foundation Trust
Public Inquiry: Exec utive Summa ry.
The Stationery O ffice , London .
Health and Social C are Information
Centre (2013) A Guide to
Confidentiality in He alth and
Social Ca re: Treating Confidential
Informatio n with Respect.
HSCIC, Leeds.
Health and Social Care
Information Cen tre, Aca demy
of Medic al Royal Colleges
(2013) Standards for the Clinical
Structure and Content of Patient
Records. HSCIC, Leeds.
Mid Staf fordshire NHS Foundation
Trust Inquir y (2010) Independent
Inquiry into Care Provided by Mid
Staffordshire NHS Foundation
Trust. January 2005 – March
2009. Volume I. The Stationery
Office, London.
Neuberger J (2013) More Care, Less
Pathway: A Review of the Liverpool
Care Pathway. The Stationer y
Office, Londo n.
NHS (2011) Clinical Use of
the Summa ry Care Record. tinyurl.
com/cdgeygu (Las t accessed:
April 15 2014.)
NHS Englan d (2014) Better
Informatio n Means Better Care.
NHS Englan d, Leeds .
Nursing and Midwife ry Coun cil
(2008) The Code: Stan dards
of Conduct, Performance and
Ethics for Nur ses and Midwives.
NMC, London.
Nursing and Midwife ry Coun cil
(2009) Record Keeping: Guidance
for Nurses and Midwives. NM C,
London.
Nursing and Midwife ry Coun cil
(2011) An nual Fitne ss to Practise
Report : 2010-2011. NMC, London.
Orwell G (1962) Inside the Whale
and Other Essays. Peng uin Book s,
London.
Public World , Unite the Union
(2014) Putting Patients First. The
Duty of Care: Pra ctical Gui dance
for Healthcare Staff. Unite the
Union, London.
Royal Colle ge of General
Pract ition ers (2013) Patient
Online: The Road Map. R CGP,
London.
Royal College of Physicians (2011)
Evidence on the Quality of Medical
Note Keeping: Gu idance fo r Use at
Appraisal and Revalidation. RCP,
London.
Unite the Union (2014) Record
Keeping and Docume ntation: A
Guide for He alth Professionals.
Unite the Union, London.
6 Now that you have
completed the article,
you might like to write
a practice profile.
Guidelines to help you are
on page 54.
045-050w36 CPD.indd 50 02/05/2014 11:58
Downloaded from RCNi.com by ${individualUser.displayName} on Mar 06, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCNi Ltd. All rights reserved.