The Law, Ethics, Professional Accountability, Nursing Documentation and Record Keeping

The Law, Ethics, Professional Accountability, Nursing Documentation and Record Keeping

High quality record keeping will help you give skilled and safe care wherever you are working. Registered Nurses have a legal
and professional duty of care (see Code of Professional Conduct, Ch. 1). According to the Nursing and Midwifery Council guide-
lines (NMC 2002) your record keeping and documentation should demonstrate:

• a full description of your assessment and the care planned and given
• relevant information about your patient or client at any giventime and what you did in response to their needs
• that you have understood and fulfilled your duty of care, that you have taken all reasonable steps to care for the patient or client and that any of your actions or things you failed to dohave not compromised their safety in any way
• a record of any arrangement you have made for the continuing care of a patient or client’.

Aims of workshops:

• To enhance the knowledge, skills and attitudes of registered nurses andother healthcare professionals in the ethical and legal responsibilities oftheir professional practice in order for them to be aware of the implicationof their actions to the overall care that they render to their patients
• To extend and enhance the knowledge and skills of registered nurses andother healthcare professionals in performing accurately and proficientlytheir responsibilities in documentation and recordkeeping

Learning Outcomes:

• Gain awareness on the concept of ethics and accountabilities indocumentation and recordkeeping and be guided with the policies, laws and provisions that will protect one’s practice
• Demonstrate skills relating to the art and science of supervision and delegation. Understand the principle of professional self-regulation and apply this to their professional practice
• Understand the cases and arguments related to Nursing and Healthcare in the UK, End of Life Care Decisions. Gain awareness on the concept of ethics and accountabilities in documentation and recordkeeping and be guided with the policies, laws and provisions that will protect one’s practice.
• Demonstrate proficiency in communication which will be important in providing accurate and factual information in documentation and recordkeeping.

Course Details

• Aims and Learning Outcomes
• The UK Law
• Sources of Law in the UK
• UK Criminal Court System
• Criminal versus Civil Law
• The Law Concerns the Nurses
• The NMC Code of Professional Conduct
• RCN Principles of Nursing Practice
• The GMC Professional Code of Conduct
• The Code Standards for Healthcare Assistant
• The Professional Accountability
• Principles of Delegation
• Three Main Nursing Ethical Principles
• Source of Guidance and Regulation for Nurses
• The Computer Misuse Act 1990
• Disclosure With and Without consent
• Disclosure to third parties
• Information Sharing Protocols
• Confidentiality after death
• Information disclosure to the police
• Police access to medical records
• Arenas of Professional Accountability
• NMC Powers
• Role of NMC Investigating Committee Panel
• Case Scenarios
• Right to Refuse
• End of Life Care Decisions
• Artificial Nutrition and Hydration (ANH)
• Record Keeping and Documentation
• Guidelines of Good Record Keeping
• Health Records
• Patient records include traditional communications
• Benchmark and Best Practice in Recordkeeping
• Common Errors in Record Keeping
• Statements and Evidence in Court
• Principles to be followed in Preparing a Statement
• Generic Medical Record Keeping Standards
• Knowledge Assessment Competency

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