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Records may differ depending on the needs of the patient or client (NMC 2004). This essay aims to identify different types of records on my placement and discuss their professional and legal implications.
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Records The Nursing and Midwifery Council believed that "record keeping is an integral part of nursing, midwifery and specialist community public health nursing practice". However, the NMC accepts that until there is national agreement between health care professions on standards and format, records may differ depending on the needs of the patient or client (NMC 2004). This essay aims to identify different types of records on my placement and discuss their professional and legal implications. In my practice placement there are two types of records: manual and computer-held records. Manual or paper based records include nurses' notes and medical notes. The main aim of the nurses' notes is to record daily observations, evaluations and reviews of patients' condition and progress in order to plan care accordingly. For example, TPR forms (temperature, pulse, BP and respiration), patient assessment and care plan, food and fluid chart, as well as urine and stool chart. However,...
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