| Description |
1 online resource (192 pages) |
| Series |
Medico-legal essentials |
| Contents |
Cover; Half Title; Title Page; Copyright Page; Contents; Foreword; Preface; About the author; Acknowledgements; 1 Introduction to health records; 2 Health records and the law; The court system; Sources of law; Guidelines and codes of practice; Court structure; Civil law; Negligence; Criminal law; 3 Accountability; Accountability in a legal context; The four areas of accountability; Legal and professional obligations; 4 Will the records stand up to legal scrutiny?; Case study; 5 Good practice for health records; The purpose of health records; Record keeping is a chore |
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What constitutes the health records and legal documents?Who should write the records?; When should the records be written?; How much should be written?; What should be written?; What to include; What to omit; Don't keep it in your head; Health records should include; 6 The detail; Inadequate detail; The rationale; Clarity of detail; Clear and unambiguous; Care and condition; Advice given; Advice and consent; Action; Negative findings; Frequency of the entries; Spelling and grammar; Missing information; Patient's details; 7 How do we record?; Protocols and guidelines; Aggression |
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Failure by the patient to complyThird party information; Telephone advice; Complaint; Recording consent issues; Understanding, language and interpreters; Dates and times; Authenticate; Designated place for recording allergies; Standard forms and tick boxes; Legibility; 8 Fact, assumption, professional opinion; Fact and assumption; Professional opinion; 9 Amending the records; Amending mental health records; 10 What to leave out; Jargon; Routine and meaningless entries; Gratuitous entries; Subjective comments; Abbreviations; Arrows and dashes; Do not squeeze information in; Do not leave gaps |
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11 Common errors in the recordsTransmitting and receiving information; Duplication of health records; 12 Sharing information; Inter-professional access to records; Communication between healthcare professionals; Confidential information; Records used for research and teaching; Records used for clinical audit; 13 Access to health records by the patient; Patient's right of access to health records; Withholding information; Children's records; Copying letters to GPs and patients; 14 Systems of record keeping; Supplementary records; Electronic records; 15 Further considerations |
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Infection control and the recordsMental health records; Midwifery records; Social care records; 16 Who owns the health records?; Patient-held records; Supplementary records; Storage of health records; 17 Health records used to prepare witness statements and reports; A statement, report or expert report?; 18 Health records used as evidence; Will your records stand up to legal scrutiny?; Untrue or false entries; Missing records; What is the court looking for?; Lack of professionalism; 19 Defensive writing; 20 Assessment criteria for health records; Glossary; Index |
| Bibliography |
Includes bibliographical references and index |
| Subject |
Medical records -- Law and legislation -- England
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Medical records -- Law and legislation -- Wales
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LAW -- Administrative Law & Regulatory Practice.
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Medical records -- Law and legislation
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England
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Wales
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| Form |
Electronic book
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| ISBN |
9781315346977 |
|
1315346974 |
|
9781498795173 |
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149879517X |
|
9781315324128 |
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1315324121 |
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