Reading List
Benson, J. (2000 July-August). Incident reporting: a vital link to organizational
performance. Home healthcare nurse manager. 4 (4), 6-10
Bernick, L. (1994 Sep/Oct) Nursing documentation: A Program to promote and sustain
improvement. Journal of Continuing Education in Nursing. v.25 (5): 203-208
Better documentation. (2003). Springhouse, Pa.: Lippincott Williams and Wilkins.
**Bjorvell, C. (2003, August). Improving documentation using a nursing model. Journal of
Advanced Nursing, 43 (4), 402-.
Burgum, M. (1996 Feb.) A new path to documentation. Australian Nursing Journal.
3(7): 38-40
Caldwell, C, Komaromy, D & Lynch, F. (2000, August 9). Working together to improve
record keeping. Nursing standard. 14 (47), 37-41.
http://www.nursing-standard.co.uk/archives/ns/vol14-47/v14w47p3741.pdf
Cummins, K.M. (1999 Mar). Charting by exception. American Journal of Nursing
99 (3): 24G , 24J
Davies, M. (2000, February). Improving documentation. Professional nurse. 15 (5),
296Dellore, C. (2004). Chapter 21. Documentation and reporting skills. In Tabbner’s
nursing care: theory and practice. 4th ed. Funnell, R … et al, eds. Sydney: Elsevier.
Dimond, B. (2005) Legal aspects of documentation. Prescription and medication
records. British Journal of Nursing.
Abstract: All nurses are required to keep contemporaneous records which are
unambiguous and legible. The NMC has reprinted the UKCC guidelines for records and
record keeping (UKCC, 1998). The Department of Health has provided advice in its
guidance on the implementation of independent nurse prescribing on the standards for
prescription writing (DH, 2002).
Dimond, B. (2005). . Exploring the principles of good record keeping in nursing. British
Journal of Nursing. 14(8): 460-2
Abstract: Record keeping is an integral part of patient care. This article considers the
basic principles which should be followed in the light of guidance from the Department of
Health, Nursing and Midwifery Council and the Clinical Negligence Scheme for Trusts.
Apart from the Mental Health Act 1983 and abortion regulations there are few statutory
provisions covering record keeping, but the courts would apply the Bolam Test of the
reasonable standard of care to documentation.
Dimond, B. (2005). Legal aspects of documentation. Mental health records. British
Journal of Nursing. 14 (21): 1132-4.
Abstract: Records relating to the detention and treatment of mentally disordered persons
are one of the few occasions on which there are statutory provisions over what must be
recorded and in what circumstances, and how corrections can be made. In the event of
a failure to comply with the statutory provisions relating to detention, the patient would
not be lawfully detained and could seek his/her release. Where a patient is admitted
informally to a psychiatric hospital, there are no statutory provisions but the general
principles discussed in an earlier article relating to record keeping should be observed.
Dimond B; (2005). Legal aspects of documentation. Exploring common deficiencies
that occur in record keeping. British Journal of Nursing; 14 (10): 568-70.
Abstract: This article discusses many of the common mistakes which occur in record
keeping including absence of clarity, failure to record action taken to meet an identified
problem, missing information, significant spelling mistakes and failures in
communication. It also considers some of the lessons on record-keeping standards
which can be drawn from reports of the Health Service Commissioner (Ombudsman).
Dimond B; Legal Aspects of Nursing (2008)
5th Edition
Written specifically for nurses, this market leading textbook provides
undergraduate students with a ‘one stop’ reference to all they need to know
about the law and its practical application to everyday nursing situations.
**Downs, C.G. (2006 Apr). Electronic Medical Records Mark a Landmark Shift in
Record Keeping. ONS News. 4: 9
Abstract: The article focuses on the importance of the electronic medical records (EMRs)
for hospital-based cancer programs and oncology practices. The functions of the
technology includes the streamlining of work flow, improving provider access to records
from remote locations and eliminating time wasted searching for misfiled records.; (AN
20301816)
Fernandez, RD. and Spragley, F. (2004). Focus on streamlined documentation.
Nursing management. 35 (10): 25-29.
Learn how an organization streamlined its documentation system to meet regulatory
requirements and to better monitor patient care outcomes and performance dimensions
Gooding, L. (2004, Sept 29). A nurse’s best defence. Nursing standard. 19 (3), 12
Hoban, V. (2005 5 July). For the record. Nursing times. 101 (27): 20-22.
Next to ‘hands-on’ care, the importance of keeping accurate records cannot be
underestimated. Developments in technology, patient rights and benchmarking now
mean that all nurses must update their record-keeping skills – or risk the consequences.
Hutchinson, C; Sharples, C. (2006). Information governance: practical implications for
record-keeping. Nursing standard. 20 (36): 59-64
This article outlines nurses’ legal and professional responsibility to adhere to good
practice in keeping patient’s notes up to date. It provides a description of information
governance issues, including paper and electronic records. The article discusses wider
issues such as the importance of good communication in record keeping and advises on
good practice in content and style
Keeping good client records
http://www.fht.org.uk/whats/a_keeping_good_client_records.htm
Keeling, J. (2003, March 4-10). How better multidisciplinary records improve care.
Nursing times, 99 (9), 33.
Kent K; (2005 Feb). Record keeping – just for the fun of it? Paediatric Nursing, 17 (1):
18-20.
Abstract: Are you a two-second scrawler, creative meanderer or accurate scribe? Katie
Dent has a serious message about the importance of communicating through records.
Kerr, C. & Lewis, D. (2000, May). Factors influencing the documentation of care.
Professional nurse. 15 (8), 516Korst, L.M. (2003, January). Nursing documentation time during implementation of an
electronic medical record. Journal of nursing administration. 33 (1), 24-30.
**Langowski, C. (2005 Apr-Jun). The Times They Are A Changing: Effects of Online
Nursing Documentation Systems. Quality Management in Health Care. 14, 2: 121-.
McGeehan, R. (2007). Best practice record keeping. Nursing standard. 21 (17): 51-55
Accurate record keeping is integral to professional practice. This article provides an
overview of the importance of good record keeping in nursing practice.
Metcalf, C. (2000, February). Changing documentation to improve stoma care.
Professional nurse. 15 (5), 307**Moloney, R. (1999 July). A systematic review of the relationships between written
manual nursing care planning, record keeping and patient outcomes. Journal of
advanced nursing, 30 (1), 51-7.
Nurses Board of Western Australia. Management of patient information and
documentation guidelines
http://www.nbwa.org.au/cpRoot/330/2/T1.4.3.003%20Pat%20Info%20and%20Doc%20G
uidelines.pdf
O’Connor, K; Earl, T. & Hancock, P. (2007). Introducing improved nursing
documentation across a trust. Nursing Times. 103 (6): 32-33
This article describes how staff training and stakeholder engagement were used in a
pilot to streamline nursing documentation and ensure its successful roll-out over an NHS
trust. The paper based documentation will be followed by electronic documentation
On the record: A practical guide to health information privacy. (1999). Auckland: Office of
the Privacy Commissioner.
Owen, K. (2005 ). Documentation in nursing practice. Nursing Standard. 19 (32): 4849
Abstract: Accurate documentation is essential to maintain continuity and inform health
professionals of ongoing care and treatment. It also provides legal evidence. This article
highlights the advantages of accurate record keeping and the barriers to effective
documentation in the community setting.
Oxtoby, K. (2004, Sept 21). Is your record-keeping up to scratch? Nursing times. 100
(38), 18-20.
Price, B. (2006). Teaching record keeping. Nursing Standard. 20(22): Suppl.
Richmond, J., (Ed.). (1997). Nursing documentation: Writing what we do. Ascot Vale,
Victoria: Ausmed.
Rodden, C & Bell, M. (2002, September 18). Record keeping: developing good
practice. Nursing standard. 17 (1), 40-42.
Smallman, S. Guidelines for records and record keeping. [London] : [UKCC],
http://www.nmc-uk.org/nmc/main/publications/guidelinesForRecordskeep.pdf
[1998].
**Smith, L.S. (2004, July). Documenting known or suspected medical device failure.
Nursing2004 34 (7), 28.
http://www.findarticles.com/p/articles/mi_qa3689/is_200407/ai_n9442041
**Smith, L.S. (2003, October). Chart smart. Handling documentation errors. Nursing
2003, 33 (10), 73.
Smith, J. (2003 Feb 11-17). Poor record-keeping can damage patient care and your
career. Nursing times. 99 (6), 33.
Sullivan, G.L. (2004, March). Does your charting measure up? RN 67 (3), 61-65
Tunney, A. M. (2003, May 21). Chart busters. Nursing Standard, 17 (36), 16-17.
Walmsley, J. (1995, April). Getting the record straight. Kai Tiaki: Nursing New Zealand,
1 (3), 28-9.
**Webster, C.S. & Anderson D.J. (2002 Aug). A practical guide to the implementation of
an effective incident reporting scheme to reduce medication error on the hospital ward.
International Journal of Nursing Practice. 8, 4: 176.
Wilson, B. (2003, May). It's all a matter of good record keeping. Australian Nursing
Journal. 10 (10), 37.
http://www.findarticles.com/p/articles/mi_go2126/is_200305/ai_n7548511
**Whyte, M. (Sep 2005) Computerised versus Handwritten records. Paediatric Nursing,
17 (7):
Abstract: The death of Victoria Climbié highlighted the worst possible consequences of
inadequate record keeping. A serious case review raised concerns about the quality of
record keeping in the paediatric intensive care unit (PICU) of a large UK children's
hospital and an audit was undertaken to compare the standard of handwritten nursing
records in the PICU with that of the computerised nursing records in the high
dependency unit (HDU). Record keeping in both PICU and HDU was found to be substandard in many respects. Both types of record keeping have their faults but the
computerised system can potentially compensate for some of the errors and omissions
that were apparent in the handwritten records. Nurses require regular training to
reinforce record keeping knowledge and skills: this has been incorporated into the
hospital's mandatory training programme. [ABSTRACT FROM AUTHOR]; (AN
18271669)
**Yocum, R.F. (2002, August). Documenting for quality patient care: chart a course for
productivity, quality, and efficiency. Nursing 2002 ; 32 (8), 58-64.
CARE PLANS
NURS 1100 : Care plan guidelines
http://home.hiwaay.net/~theholt1/NURS1100/careplan.htm
Richmond, J. (Ed.). (1997). Nursing documentation: Writing what we do. Ascot Vale,
Victoria: Ausmed.
**Denotes item can be downloaded from CINAHL