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Dated and Timed

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The NMC requires that all records be dated and timed, and all records must be made in a timely fashion as soon as the event as is reasonably possible, and The Code emphasises this. All computer records will be automatically dated and time‐stamped when the record is made; however, the computer will not recognise that a record may relate to an event that occurred two hours ago and the time attributed to the record will be the current time. Therefore, it is imperative that all nursing associates attribute the correct time. The same can occur during the night where a record is made after midnight relating to an episode of care that occurred before midnight. In this instance, the date as well as the time needs to be correctly identified. This applies equally in a written record, but the written record will make no automatic assumption or entry in relation to the date and time, and the nursing associate must make this a clear part of any record that they make. The timing of a record demonstrates the sequence of care events. Ideally, records are made at the time of the event and, therefore, will be in the correct chronological order; however, when this is not possible, it is a good practice to indicate the time that the record relates to so that anyone examining the records historically (in retrospect) can establish a time line of events. The format of the time must be considered; the 24‐hour clock is much harder to confuse in a record that uses the 12‐hour clock. For example, in the 12‐hour clock, 1 o’clock appears twice, whereas in the 24‐hour clock, these are clearly written as 01:00 h and 13:00 h. Recording 1 a.m. and 1 p.m. can be confusing, and the differentiation in the 24‐hour clock is very clear. The final NMC element of The Code with regards to record‐keeping is the issue of speculation.

The Nursing Associate's Handbook of Clinical Skills

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