Exam 18: Record-Keeping and Documentation

The record should be written up as soon as possible after the episode of care and any temporary note taking, for example in an emergency situation, should be formalized within ------------------ hours.

Records are usually kept for a minimum of ---- years for an adult over 21.

Which one of the following is a legal requirement to be complied with in relation to records?

Record keeping or rather, poor record keeping is the ----------- highest reason why registered nurses are removed from the professional register.

The entry should have the time entered using a ----------------------- hour clock.

A student nurse you must have each record you write in a patients notes countersigned by a qualified nurse until they are deemed as --------------------- in record keeping.

Patients can now request to see all of their medical records, they are no longer a secret. The ----------------------Act helped to bring this change about.

The fundamental principle in relation to record keeping is that if it is not recorded it did not ------------------------

Records should be Clear, Intelligible and _______?

The NMC ------ is the current published guidance for record keeping.

TPR is an acceptable or unacceptable abbreviation

Clients / patients records must be kept safe and stored appropriately to maintain ----------------------------------

Nurses often blame lack of ------------------- a reason for poor record keeping

The E in the No Elbow Rule stands for _______?

What colour ink can be used when writing in patients records?

What does contemporaneous mean?

When writing in patients' notes what must always be there?

Record keeping is an integral part of care delivery and enhances -----------------between the health care team.

The Nursing and Midwifery Council (NMC) (2015) state that nurses must 'keep clear and accurate - - - - - - relevant to your practice'.

Who adopts the approach that "if it is not recorded, it has not happened"?