Procedure/Technique Outpatient Residential Home Surgical Ward What
Clinic could
happ
en if
these
proce
dures
/tech
nique
s
were
not in
place
?
Documentation and Records Staff are trained in record keeping There are four categories of
record keeping are kept and are taught the importance of hospital records, these are:
all entries should be: on the updating and referring to these filed. 1. Patients clinical record – This
clear and legible compute The Care Quality Commission is information of events in the
Signed r and are (CQC) have a certain regulation patients illness/progress in
In line with local accesse relating especially to keeping recovery and the type of care
policy d using a accurate care records, there are 28 provided. These notes are
Accurate and log in regulations that encourage care legal, evidence to the patient
clear to all and homes to ensure high quality that their case is being
involved in the passwor records are kept. Families are managed, prevents
care d encouraged to check the records to duplication of work,
Factual all ensure they are correct. The infromation for medical and
An account of the records residents care plan will outline all of legal nursing research, helps
care given made on the care they receive, this includes in the promotion of health
Identify any paper their medication, dosage, frequency and care and is legal
problems and must be and on what dates. Care staff will protection to the hospital
how these can be transferr have a written record of what care doctor and nurse.this could
resolved ed to the they have provided that day and if be a nurses’ admission
, Not altered or clinical they have had any concerns or if the assessment, grapphic sheet
destroyed record residents health has changed in any and flow sheet – vital signs,
Dated and signed as soon way. medical history, medication
Readable as https:// records, progress notes.
possible. www.nhshighland.scot.nhs.uk/ 2. Individual staff records –
Any Publications/Documents/Leaflets/ these are a separate set of
pieces of Infection%20Control%20Guidelines records that are needed for
paper %20for%20Care%20Homes.pdf each member of staff, this
must be gives details of their sickness
identified and absences, their
with the development activities and
patient’s personnel notes
full name 3. Ward records – these are the
and date records for a particular ward,
of birth/ this includes a ward
NHS inventory book, staff patient
number assignment record, circular
Complet record, round book etc.
ed in 4. Administrative records with
black educational value – this
ink/typed includes a treatment register,
Dated admission and discharge
and register, personnel
times, performance register,
24-hour organisation chart, procedure
clock manual
Minimum A nurse completes a nursing history
use of form when a patient is admitted to a
abbrevia nursing unit, this has recently been
tions changed to electronic but there is
All also a paper copy, it includes a
sections patients vital signs, allergies,
