“There is a lot of information about good documentation in care. While it is often tied to the legal meaning of an accurate record, it`s important to remember that documentation is also a great way to connect with your peers. In addition, it can contribute to the assessment of care and decisions about continuing care, as well as the treatment of the service user. This chapter discusses and analyses the legal and professional framework that governs the practice of midwifery and the midwife`s responsibility for documenting her records. Practical activities and exercises are included throughout to help you integrate domain theory into practice and offer practical advice and advice on how to improve your personal level of recording. Effective recording and documentation is an essential part of the roles of all health professionals, including nurses, and can support the delivery of safe, high-quality patient care. This article explains the importance of recording and documentation in nursing and health care and describes the principles for maintaining clear and accurate patient records. The Council of Nurses and Midwives was founded on April 1, 2002. It was the successor to the former professional association, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC).
With the creation of the NMC, the new rules for midwives came into effect on January 1, 2013, and the NMC will continue to set practice requirements and provide guidance on the standards that can reasonably be expected of midwifery. • How to use the information in this article to educate nursing students and colleagues about the importance and principles of effective registration and documentation. Standards and guidelines developed by our regulatory body, the Council of Nurses and Midwives (NMC), on the role and responsibility of midwives in the context of effective documentation and professional practice (NMC 2008, 2009a, 2012a) are reviewed, analyzed and applied to practice. It is expected that, after reading this chapter, the reader will be able to describe the various forms of recording used in contemporary practice and discuss the reasons for maintaining complete and contemporary records in terms of professional liability. A self-audit and peer audit tool will be put in place to monitor the record standard will be introduced to enable the reader to apply knowledge and skills in practice, assess and enhance the development of their own record-keeping skills. • How this article could improve your practice in terms of effective recording and documentation. No matter what system you use, you need to follow clear rules to make sure your documentation is accessible. It is important that others can understand what you have registered and what it means for the user of the service you are interested in.
Midwifery rules and standards make it clear that midwives are responsible for the quality and preservation of their documentation (NMC 2012a). “All records of the care of the woman or baby must be kept in a secure place for 25 years” (p. 18). This rule applies wherever the midwife performs her duties, whether in the private, governmental, independent or national (NHS) health service. Do not change or change other people`s documentation if you need to change your letter Draw a clear line, sign and date any changes Registered nurses may delegate the file to licensed practical nurses, practical assistants and nursing students. While they can document their care, a countersignature is required until the employee is deemed competent. However, a registered nurse should not countersign if she has not witnessed the activity. All nurses should be aware of local document counterclosure guidelines (NCR 2017) Brooks N (2021) How to Conduct Effective Records and Documentation. Standard of care. doi: 10.7748/ns.2021.e11700 Complete all records correctly and without tampering, and take immediate and appropriate action if you determine that someone has not complied with these requirements Effective documentation is part of the midwife`s duty of care. The midwife is expected to use professional judgment to make decisions that improve client service through her documentation.
The NMC states in its Records and Records Guidelines that it “is not a set of rules that provides answers to every question or problem that may arise” (NMC 2005, p. 5). However, it is intended to be used with midwifery rules and standards as a guide to achieving excellence in cases.
