Читать книгу The Nursing Associate's Handbook of Clinical Skills - Группа авторов - Страница 206

These are two terms used by the NMC which possibly have similar meaning, although clearly written could be interpreted as more than just legibility. To reiterate, the nursing associate must ensure that all records are made in such a way that they can be read by another healthcare and social care professional. Legibility is therefore very important to ensure that all records made communicate necessary information about the patient for whom the record has been made. As discussed previously, when looking at who has access to records, it was seen that a number of professionals, including the legal community, police as well as healthcare and social care professionals can also access records, and as such, content must not be ambiguous or difficult to read or decipher. Legibility requires that when a record is made by hand, black indelible ink is used, and pencil must not be used as this can be erased and rewritten at any time. Furthermore, many pencil leads fade with time; therefore, this does not make a permanent record. Often, local policy requires all record makers use black ink as this can be more permanent and photocopies and scans better than blue ink. If in doubt as to what a local policy is on record‐keeping, then using black ink is always a safe default position; you must seek advice if you are unsure. Legibility is also concerned with the alteration of a record in a clear way. A record that has been clearly written will also consider other issues such as language.