Documentation and Record Keeping

Abstract

Documentation and record keeping is an important aspect of healthcare practice and perioperative practice is no exception to this rule. For some time now, recording every activity or intervention that a patient receives has assisted with enhancing perioperative practice; equally, it has played a key part in resolving legal and professional incidents that have occurred. There are numerous national guidelines that uphold accurate record keeping as an intrinsic aspect to patient safety (DH 2006, HPC 2008, NMC 2008, Scottish Executive 2008, DH 2009). The intention of this article is to identify and discuss some of the more common errors associated with record keeping which may have a direct or indirect effect on practitioners’ misconceptions of using electronic record systems.