THE DATA PROTECTION Act 1998 defines a health record as any electronic or paper

1. In 1992 Toms identified that nurses did not consider record keeping a high priority activity, and this remains an issue today. The annual report of professional conduct produced by the NMC for 2002-2003 highlighted that issues regarding clinical practice, including failure to keep accurate records, were the biggest category of offence, accounting for 30 per cent of all charges made (NMC 2003). Nurses continue to be removed from the professional register for failing to keep accurate records, which is an ongoing area of concern. THE DATA PROTECTION Act 1998 defines a health record as any electronic or paper information recorded about a person for the purpose of managing his or her health care. Adey, Sofia, Liz

2. NMC Records and Record Keeping, (2007) • Be factual, consistent and accurate, written in a way that the meaning is clear; • Be recorded as soon as possible after an event has occurred, providing current information on the care and condition of the patient / client. • Be recorded clearly and in such a manner that the text cannot be erased or deleted without a record of change. • Be recorded in such a manner that any justifiable alterations or additions are dated, timed and signed or clearly attributed to a named person in an identifiable role in such a way that the original entry can still be read clearly. • Be accurately dated, timed and signed, with the signature printed alongside the first entry where this is a written record, and attributed to a named person in an identifiable role for electronic records. • Not include abbreviations, jargon, meaningless phrases, irrelevant speculation, offensive or subjective statements.

3. NMC Guidelines for the Administration of Medicines • Accountable for your actions/omissions when administering medication – you must apply professional judgement and knowledge. Principles • Know the therapeutic uses of the medicine to be administered. • Identify the patient to whom the medicine is being administered. • Awareness of patient’s care plan. • Consider dosage, method of administration, route and timing. • When supervising a student nurse in administration, clearly countersign the signature of the student. • It is unacceptable to prepare substances for injection in advance of their immediate use. • Do not administer medicines drawn up by another practitioner when not in their presence. Management of Errors • Must report immediately. • Require thorough and careful investigation – taking into account the context and circumstances. • Sensitive management and comprehensive assessment will be applied. • NMC will consider whether the error is due to reckless or incompetent practice.

4. Accountability Advice Sheet (NMC, 2004). Nurses hold a position of responsibility and people rely on this. Nurses are professionally accountable to: • -NMC. • -Employer. • -Law. • -Patient. • “As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions.” • Nurses must act in the best interest of the person in their care at all times. • If the nurse is delegating care they must delegate effectively and are accountable for the appropriateness of the delegation. • Nurses must; • Establish that anyone they delegate to is able to carry out their instructions. • Confirm that the outcome of any delegated task meets required standards. • Make sure that everyone they are responsible for is supervised and supported. • Accountability is integral to professional practice.

5. The Code: Standards of conduct, performance and ethics for nurses and midwives (NMC, 2004). • Be open and honest, act with integrity and uphold the reputation of your profession. • Failure to comply with code may bring fitness to practice into question and endanger registration. • You must work with colleagues to monitor the quality of your work and maintain the safety of those in your care. • Share information with your colleagues. • You must facilitate students to develop their competence. • Delegate effectively. • You must establish that anyone you delegate to is able to carry out your instructions. • You must confirm that the outcome of any delegated task meets required standards. • You must make sure that everyone you are responsible for is supervised and supported. • Manage risk. • You must act without delay if you believe that you may be putting someone at risk. • Deal with problems. • You must act immediately to put matters right if someone in your care has suffered harm for any reason. • You must explain fully and promptly to the person affected what has happened and the likely effects.

6. References • Data Protection Act (1998) The Home Office. The Stationery Office, Norwich. • Nursing and Midwifery Council (NMC) (2007) Record Keeping, London. • NMC (2008) The code; standards of conduct, performance and ethics for nurses and midwives, London. • NMC (2004) Accountability advice sheet, London • Professional Conduct Annual Report (2002-2003). NMC, London. www.hmso.gov.uk • Toms EC (1992) Evaluating the quality of patient care in district nursing. Journal of Advanced Nursing. 17(12), pp1489-1495.