Article topics: Accountability, Confidentiality, Electronic medical records, Professional and legal requirements, Record-keeping, The law
Record-keeping is an integral part of the general practice nurse’s (GPN’s) skill set.
The new Nursing and Midwifery Council code of conduct (NMC, 2015) has record-keeping threaded throughout the new four standards highlighting its importance for all practitioners.
Electronic Medical Records (EMR) used by GPNs aid the production of chronological and contemporaneous records.
Poor records are often reflective of poor practice.
GPNs need to always consider both professional and legal requirements for record-keeping.