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Medical Records for Nurses in Primary Care

Post date: 10/10/2017 | Time to read article: 1 mins

The information within this article was correct at the time of publishing. Last updated 06/02/2019

Poor record keeping is a major factor in litigation cases brought against healthcare professionals

Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. They should be comprehensive enough to allow a colleague to carry on where you left off.

The medical records you keep provide a window on the clinical judgment being exercised at the time. Therefore, not only are good medical records essential for continuity of patient care they are also vital for defending you if you face a complaint or clinical negligence claim. 

By attending this workshop you will:

  • build your knowledge of the principles of good record keeping
  • have an appreciation of some of the regulatory, contractual and legal requirements regarding record keeping
  • gain an understanding of how to make good clinical entries
  • learn specific tools and techniques to improve the making and keeping of medical records
  • develop the skills to assess the quality of your own record keeping. 

On completion of this workshop you will be presented with a certificate of attendance, including space for you to record your reflective learning.

Membership of MPS

MPS membership for nurses is free when the practice is part of a Practice Xtra Package, for more information about this click here

If you are interested in commissioning this workshop for your organisation, please contact MPS Educational Services for more information and costs.

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