[The regulation of nursing record-keeping]

Record-keeping guarantees a permanent trace of a patient's treatment and the legal protection of the nurse. Legislation provides a regulatory framework. It is also a matter of professionalisation and improvement of practices.

[Ethical and Legal Aspects That Consider in the Medical History of the Elderly]

Nurses regularly use the patient's clinical history and we interact through it with multi and interdisciplinary team with the purpose of providing comprehensive care to the elderly. We make professional use of personal patient information with this interaction, as well we generate the nursing care plan and nursing records. We also perform comprehensive geriatric assessment and other specific registers aimed at elderly care, which have a clear impact on patient health care. The progress and regulatory complexity on the use of medical history, new strategies of the relationship in the context of care, based on bioethics, as well as the active role of nurses in the creation of information, makes necessary to review the ethical and legal issues surrounding this document, in this case, in elderly patients.

Records—The Achilles’ Heel of School Nursing: Answers to Bothersome Questions

This article addresses practice issues related to school health records and school nursing documentation. Because the issues have been posed by practicing school nurses, the article is in Question and Answer (Q&A) format. Specifically, the questions addressed concern the following: ownership and storage location of student health records when the school nurse is contracted from a community health agency rather than employed by the school district; documentation of sensitive health information on students’ health records including pregnancy, drug and alcohol abuse, mental illness, history of suicide attempt, and HIV status; inclusion of medical diagnoses and current medications on a student’s Individual Educational Program (IEP); and Health Insurance Portability and Accountability Act (HIPAA)-permitted communications between school nurses and health care providers related to students’ immunization status, regarding a student’s treatment needs in school, and via facsimile (e.g., records of immunizations, completed physical examination forms, and medical orders). HIPAA, the Family Educational Records and Privacy Act (FERPA), and other laws are addressed as appropriate, and resources for obtaining further information are included.

Think about your ink

During my nursing career, I did what you do - blue or black for day shifts and red ink for night shifts. This allowed us to quickly find an entry as the night shifts stood out from the day entries.

'Fear of litigation is compromising care'

Care homes are allocating far too much time to paperwork at the expense of face-to-face patient care because they are fearful of being blamed or sued if their records are not up to scratch, a social reform charity said.

Improving record keeping: important lessons for nurses

Professor Alan Glasper discusses the importance of record keeping for nurses and the clear, intelligible and accurate (C I A) gold standard toward which health professionals should strive.

Improved record-keeping with reading handovers

Nursing handover has traditionally been performed orally and apart from patients. Results of an audit undertaken at the Royal United Hospital, Bath, suggest that record-keeping standards there were poor. To improve these standards, a method of 'reading handover', in which the main method of communication between nurses on different shifts is written rather than oral, was introduced on one ward. This article discusses the results of this pilot study and suggests that the new handover method has improved standards of record keeping.

Nursing liability and chain of command

SCENARIO: A FIVE-DAY-OLD INFANT is diagnosed with systemic Candida albicans (yeast). During rounds, the resident physician is told to start 5FC (flucytosine). When the order is written, it is for 5FU (fluorouracil, a cancer drug). The medication arrives on the unit; the nurse checks it against the order and determines that it is for the right patient, right dose, right route, right time, and, according to the order, right drug. The infant receives the drug from nurses on two shifts. The nurse on the night shift, a new nurse, asks why the infant is receiving a cancer drug. She calls the pharmacy to question it, then calls the resident physician and is told that it was what the attending physician said to order. Despite the nurse’s insistence that this is not the right drug, the resident demands that she give the drug as ordered. She gives the drug. The next morning the infant dies. A lawsuit is brought in which the resident, attending physicians, and hospital are named as defendants. The hospital is sued because of the negligence of its nurses who failed to question the order to give 5FU.

Informing patients of risks inherent in treatment

Consent to treatment lies at the heart of autonomous decision making by patients who are entitled to make a free choice about whether to accept or refuse treatment. To help patients arrive at their decision district nurses must ensure that they give sufficient information about the nature and risks inherent in the treatment to allow an informed choice to be made. This article considers how much information regarding risks needs to be disclosed. It discusses how the law requires a different level of disclosure for patients who ask no questions about risks, those who make general enquiries about risks and those who ask specific questions about the risks inherent in treatment.