Records management guidance and its implications for research

The UK Department of Health's code of practice for managing records has important implications for nurse researchers. Naomi Reay and Jill Firth consider the steps researchers need to take to comply with the code.

Your choice: documentation or litigation?

As the nursing shortage worsens and the care required by the elderly population increases and becomes more complex, the need for accurate, portable, and permanent electronic documentation methods will and must become an integral part of gerontological nurses' routine recordkeeping. Integrating technology into care regimens is inevitable. Gerontological nurses must exert their leadership so the newest technology can be used to both improve the care of older patients while protecting those who provide that care.

Documentation, Part 1

This article discusses principles that inform all good methods of charting and examines an actual court case to illustrate how adequate documentation can protect nurses against allegations of negligence and malpractice. Also discussed are the importance of preserving the medical record and mistakes commonly made in charting that leave nurses vulnerable to lawsuits.

Documentation, Part 2

Properly documenting care in a patient's medical records is essential and, in the event of a lawsuit, provides evidence that the care that was provided met professional standards. Even nurses who meet the standards of care must document that care fully and accurately to avoid being vulnerable to accusations of malpractice that may result in costly jury verdicts and court decisions.

Caring for the incarcerated in the intensive care unit

In the United States, jail and prison populations continue to be on the rise. In 1976, the US Supreme Court mandated correctional facilities to provide necessary medical care to all incarcerated individuals. Often, this population is frequently associated with chronic illnesses and accidental injuries that require admission to the intensive care unit. This article will be a case presentation of a critically ill patient and a brief discussion of safe and effective interventions of the incarcerated patient in the intensive care unit.

Best practice in record-keeping

Accurate record-keeping is integral to professional practice. This article provides an overview of the importance of good record-keeping in nursing practice.