Unit Five Questions. Claims of poor record keeping and tardiness – maybe give that one a miss. It is neither protecting the public or the registrants and ultimately is putting both group's lives at risk.The current systems leaves it wide open to abuse by vexatious managers or colleagues with a grudge. The issue for businesses is a complex one, but the key points to bring out in regard to poor records keeping are: If the records are shown to be poor then the officer has in effect shown that the figures on the tax return cannot be relied upon and the officer could then look make assessments for under declared profits. Charles Ocici observed that poor record keeping is one of the major reasons why companies collapse. Unit Three Questions. In one example, a registrant sent the NMC copies The nurse regulator breached confidentiality or data-handling rules in 11 of 100 fitness to practise cases checked by auditors. Investigations were poor, decision-making flawed and record-keeping lax, says the PSA. Principle Standards for the use of Abbreviations within Health and Social Care settings can be found at reference 10. According to the Nursing and Midwifery Council (NMC, 2009b) an average of 8.8% of Fitness to Practice cases referred annually to them concern poor record keeping. This practice requirement is presented in the NMC Code. The provision of a record keeping policy provides the framework to guide professional practice. Specifically, section 3 and 10. No standard model . Home; Hearings; Recent decisions; Recent decisions Print page Share Tweet. The report also stated that “last year nearly 10% of the cases that went to a full hearing were to do with poor record keeping”. Pages 24 - 27 Style and content. Be very clear about the occasions on which you have noticed poor timekeeping as this helps to focus the conversation and try not to generalise. Registration. It replaces the Joint BDA/Dietitians Board Guidance on Standards for Records and Record Keeping … The RCN (2003) has published guidelines specifically for colorectal and stoma care nursing. CG2 – Record Keeping Guidelines Clinical Governance V3 March 2010 1 NHS Professionals CG2 – Record Keeping Guidelines Introduction Record-keeping is an integral part of Nursing, Midwifery and Allied Health Professionals’ practice and is essential to the provision of safe and effective care. explore a-z of composers. It is not an optional extra to be fitted in if circumstances allow (NMC 2009). Record your concerns, including any minor concerns, and the details of any action you have taken, information you have shared and decisions you have made relating to those concerns. With poor record keeping at the center, there’s a range of risks that ripple outward in all directions. Poor record keeping is a major factor in litigation cases brought against healthcare professionals.3 When patients seek legal advice—for example, in cases of malpractice allegations—the attorney’s first task is to review the patient’s notes and determine whether any injuries were caused by negligence. Record keeping is a fundamental part of professional practice. Therefore in conclusion the consequences of poor record keeping should promote the maintaining of a good standard of relevant record keeping in line with the NMC (2009) record keeping guidance. Pages 19 - 22 Legal and professional issues in health record keeping. This list should be attached to patients’ records (Andrews, 2002; NMC, 2002c; Dimond, 1999). Pages 23 Unit Five. Vigilance is required to ensure high standards in record-keeping, whether records are in written or electronic form. Case studies Documentation & medical records. The current design was introduced … This guidance on record keeping was published in July 2009, for implementation from 1 August 2009. Meeting our standards. Good record keeping is essential to the provision of safe, effective person centred care. Poor record-keeping by nurses is a feature of many of the complaints to the Health Service Ombudsman (2000) and may result in compromised patient care owing to poor communication. NMC Panel hearing - criminal conviction I represented [October 2016] a nurse who was the subject of an NMC fitness to practice referral, having been convicted of a racially aggravated criminal offence involving public violence. 4.6 Where the nursing and/or multi-disciplinary team assessment of a The important activity of making and keeping records is an essential and integral part of our activity and should not be seen as a distraction. This CPD article highlighted how patient records are clinical tools that act as evidence of care, or the lack of it, and are relevant to every nurses practice. „Poor records mean a poor defence and no records means no defence.‟ (Tingle, 1998). Poor practices for information governance and poor record-keeping led to confidentiality or data breaches in 11 cases.' Summary. Record Keeping tool for professional (NMC, 2009a). Suggestions {{search.Title}} Home. Showing 1 to 25 of 543. New releases from NMC Recordings and Birmingham Record Company Browse all our 2020 releases in the NMC Shop. Case Study: Tragic case emphasises good clinical record keeping A case involving a woman who launched a multi-million dollar law suit against a GP for failing to diagnose a rare form of meningitis which rendered her blind and deaf, reinforces the importance of keeping detailed medical notes. Page 28 References and further reading. The NMC was not frank and open with families and patients. Page 29. 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