Читать книгу The Nursing Associate's Handbook of Clinical Skills - Группа авторов - Страница 195

The saying ‘If it is not written it did not happen’ has been the focus of record‐keeping texts and lectures for many years. This simple statement contains many more complex truths that will be addressed throughout this chapter.

The Nursing and Midwifery Council (NMC) standards of proficiency (2018b) for nursing associates indicate that there are many aspects of communication that must be considered by the nursing associate, and this is explored within this chapter and other chapters of this text. This chapter explores the essential aspects of communication that pertain to the need to communicate both effectively and efficiently through written records and refers to the six platforms found within the Standards of Proficiency (2018b) as well as the NMC Code (2018a). This chapter explores the subject of record‐keeping from both professional and legal viewpoints. A good starting point is to consider the purpose of a written record.

The Nursing and Midwifery Council (2018b) standards of proficiency for nursing associates represent the standards of knowledge and skills that a nursing associate must meet to be registered by the NMC as a safe and effective nursing associate. The following proficiencies apply to this chapter:

1 1.10 write accurate, clear, legible records and documentation

2 1.10 clearly record digital information and data

3 1.11 provide clear verbal, digital or written information and instructions when sharing information, delegating or handing over responsibility for care

4 1.14 demonstrate the ability to keep complete, clear, accurate and timely records

5 3.18 demonstrate the ability to monitor the effectiveness of care in partnership with people, families and carers. Document progress and report outcomes

The NMC updated its Code (Nursing and Midwifery Council 2018a) to ensure that nursing associates were also equally provided for by the NMC with a set of standards to ensure the protection of the public. In this chapter, this publication will be simply referred to as The Code.