A record is information created or received that provides evidence of business activities. Each individual document is not necessarily a record. Records are the organisation's documentary heritage that provides evidence of the transactions, decisions and events that may need to be proven or referenced over the medium or long term. As such, they are an important corporate asset.
Traditionally, records were held in paper format but are now increasingly created in electronic systems such as word processing, spreadsheets, databases and email software
Based on Museum of London website: http://www.collectionslink.org.uk/RM-Tool/s01p02.html
“In providing care you must … keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment; make records at the same time as the events you are recording or as soon as possible afterwards.”
“Record keeping is an integral part of nursing, midwifery and health visiting practice. It is a tool of professional practice and one which should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow”
NO ‘Patient fell out of bed’
‘Where were you standing and did you see it?
YES ‘I found the patient on the floor in a position consistent with a fall’ or
I found the patient on the floor and Mrs Smith (patient) reported she fell out of the bed’
- This is what we saw
- This is what we heard
NB Anything written in documentation is fully disclosable unless we believe it is in the best interest clinically for the patient not to see it written down
96% Preparation, 2% Luck, 2% Law