Good Record-Keeping and Its Implementation

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Good Record-Keeping and it's implementation

This essay outlines the need for good record keeping. It will discuss the Nursing and Midwifery Council (2009) guidance for nurses and midwives.

The Nursing and Midwifery Council (NMC 2009) have guidelines for good record keeping. They state "good record keeping is crucial to the provision of safe and effective care and an integral part of nursing and midwifery: not an optional extra to be fitted in if circumstances allow".

It helps midwives provide the correct and safe care for women in their care. The process of record keeping is every bit as important as hands on clinical skills to helping maintain woman's safety. It is not only important for monitoring a woman's treatment and medical condition, it is also important for any legal issues that may arise (Wood 2010).

A main point in the NMC 2009 guidelines for good record keeping 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. A written assessment should commence a care plan and will include vital information on the woman's medical condition and what their care needs are. It is also important to have all information regarding next of kin in case a woman's condition was to deteriorate. As part of the assessment it is vital to a woman's safety that information regarding any medication is included. This can highlight what a woman may be taking at the present time or any medication that they have an allergy to. If information regarding allergies is clearly documented then all care staff involved are aware when delivering care to the woman (Kathawala 2010). The NMC (2009) also state "hand writing

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