This learning module considers best practice in record-keeping and documentation in light of recent public inquiries and reports, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. Collaborative approaches to planning and evaluating care, and the greater emphasis on patient ownership of information that concerns them, are highlighted.It is important to note that the principles discussed here can be applied to other healthcare environments, notably the care home setting.
Don't forget that you don't have to complete our two-hour learning modules all in one go. Tailor your learning to fit your busy schedule by undertaking one or two sections at a time. You can stop and save your learning at any point, and pick up where you left off when you return.
This learning module for nurses aims to set the nursing practice of record-keeping in the context of recent public inquiries and guidance, as well as current policy and legislation. It discusses the risks, challenges and opportunities of electronic record-keeping. It also considers record-keeping in the context of collaborative working with patients, service users and colleagues from other professions.
After reading this module and completing the time out activities you should be able to:
This learning module is broken down into the following sections:
Disclaimer
Please note that information provided by RCNi Learning is not sufficient to ensure competence in the skill. Assessment of competence should take place in line with local practice. Practice should always align with local protocols and procedures, latest guidelines and any regulatory code. All modules should currently be viewed together with available national and local Covid-19 guidelines. For advice, go to www.rcn.org.uk/covid-19/rcn-position
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All our modules include CPD certificates. They are evidence-based and have been subject to an external double-blind peer review.
Personal revalidation RCNi Revalidation Portfolio to document learning. Download as a PDF to submit to the NMC
Log CPD hours, write a reflective account and save certificate into RCNi Revalidation Portfolio
Pre and post module tests let you measure your progress. Further reading list included