It will briefly discuss the nursing and midwifery council 2009 guidance for nurse's and midwives and the importance of good record keeping in the health care setting. The first principle is of detailed assessment and reviews which helps set up a care plan. It then moves on to the next principle which discusses hand writing and how it should be written legible. The next principle that has been discussed is the one that records should be accurate and recorded in a way that meaning is clear. Finally the last principle that has been discussed is that records should be factual and not include unnecessary abbreviations, jargon, meaningless phrases or irrelevant speculation.

It then progressively moves on to discuss how these four principles impact on a care plan and how they are maintained. The nursing and midwifery council nmc 2009:1 have guidelines for good record keeping, this helps nurses maintain good record keeping skills. Good record keeping skills is an important part of a nurse's role in the health care setting.

Computer documentation is used in many of the health care settings, however hand writing in documentation is still widely used. The process of record keeping is every bit as important as hands on clinical skills to helping maintain patient's safety within the health care setting. It is not only important for monitoring a patient's treatment and medical condition, it is also important for any legal issues that may arise when providing care to a patient regarding any care or treatment they have received when in a health care setting griffith 2003 . There is a principle in the nmc 2009 for good record keeping that states you should record details of any assessment 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 nmc 2009. This principle can help when putting a care plan in place for the care needs of a patient.

When a patient first comes into any health care setting the first form of documentation is a written assessment of the patient and what their care needs are. This is a very important part of record keeping as it is the beginning of the care planning process. Assessment forms will include vital information on the patient's medical condition and what their care needs are. It is also important to have all information regarding next of kin in case a patient's condition was to deteriorate miller and gibb 20. A part of an assessment that is vital to a patient's safety can be information regarding any medication. This can highlight what a patient may be taking at the present time or any medication that they have an allergy to.

Academic English Writing Skills Ugent

If information regarding allergies is clearly documented then all care staff involved are aware when delivering care to the patient diamond 20. The next stage in the care planning process is to put a plan into action to what treatment is best for the patient's needs. All aspects of the patient's care needs get reviewed so that all the patient's care needs can be met. This stage involves the nurse in charge of the patient getting referrals from other care professionals to meet the care needs of the patient. Evaluation is the final part of a care plan which looks at all the information recorded in a care plan.

If the care needs of the patient have not been met then the health care professionals are able to make changes to the care plan for the best interest of the patient. This may include professionals at a different skill level, specificaly to deliver that care and treatment. It is the health care professional's responsibility to record and review all information regarding patients care. This enables care progress and makes sure the patient's care needs are being met safely brooker and waugh 2007 358. One of the principles for good record keeping is regarding handwriting hand writing should be legible nmc 2009. A way in which badly written documents can cause problems is if prescribed medication that has been recorded is not written clearly, not only the type of medication but also information on administering medication. If a patient's records are written clearly there is less risk to the patient's safety reddy 20.

In any care setting good writing skills are very important as other multidisciplinary teams can be involved in a patient's care. It is important that they can easily read any treatment and care a patient is receiving and that all needs of the patient are being met. A care plan is a legal document so it is vital that all information can be easily read.

Any care professional who writes any information in a care plan is personally responsible for the information that they have written powell 20. When a nurse writes in a care plan regarding treatment to a patient they may make a mistake and need to correct what they have written, this is the only reason why information can be changed. Correction fluid should never be used in a care plan to cover any written mistake. A line should be put through the error that has been made and the appropriate notes should be written in. The person making the change to the care plan should sign and date when they made the correction so other health care professionals can see why the correction was made to the care plan diamond 2001.

This makes all written information in a patient's or clients care plan more easily to read and any individual who writes in the care notes should try and use a black ink pen on white paper. A patient's care plan is the main tool used in a care setting to communicate with different care professionals and services who may be involved in the care of a patient. In a variety of different care settings different coloured paper is used for certain medical interventions. It is important that any paper and ink that is used in a care plan can be easily photocopied, as at times copies of some of the patient's care plans may be needed griffith 2003. There is also a principle in the nmc that states your records should be accurate and recorded in a way that the meaning is clear. All notes that are written about a patient's care should be clear so that any other care professionals who need to read the care plan know and understand what has been written.

If a nurse was to write settled day what meaning does that actually have to other care staff. If there has been a problem regarding a patient's care and it has been resolved then this has to be clearly documented. When a nurse comes on shift and takes over the care of a patient and the patient's care notes may read awake most of the night due to being in pain and then did not write how she helped the patient overcome this problem then this is poor record keeping skills. Highlighting every intervention while delivering care is vital and information should not be missed out. It may be the case that the patient received pain relief medication at the end of that previous nurse's shift. If this was not documented in the patient's care notes or kardex then the nurse who has taken over care of the patient may administer pain relief again, putting the patient's safety risk. Documenting and recording clear and meaningful information regarding a patient's care and any changes in a patient's condition is a skill, and it is essential care professional in a care setting get it right.