Complete title:
Royal College of Nursing Guidance Document - Consent to create, amend, access and share eHealth Records
Description (short summary):
Record keeping is an essential element of nursing practice; it is an important method of communication, it is used to monitor the quality of patient/client care, and serves as a legal record of a practitioner’s care.
The principles of good record keeping in nursing are well established and apply equally to computerised or paper records. The Royal College of Nursing (RCN) supports the introduction of electronic records, but is concerned to ensure the protection of both patients and nursing staff (nurses and other health care workers) in their use.
As electronic records become increasingly common place nursing staff need to familiarise themselves with the key concerns associated with their use. Many of these relate to issues of consent - what information is going to be included, who will see it, who it will be shared with, and what rights apply. The governments of all four UK countries have produced and publicised information for patients/clients about their rights and the answers to these questions.
This booklet has been prepared to clarify the RCN position on these issues, and to help nursing staff to understand the issues and their responsibilities so that they can help patients to make choices in relation to their personal records. It sets out basic principles, and offers guidance to front line practitioners involved in making decisions about their own use of electronic patient records, and who have responsibility for explaining the position to patients and helping them to make their decisions.
The booklet is framed around several principal questions that practitioners might have about using electronic patient records, but it does not provide an exhaustive review of all the issues. For ease of reference, key RCN position statements are highlighted.
While the examples shown in this document may refer to the National Health Service (NHS) in the UK, the principles illustrated are also relevant to other sectors (such as the independent sector), as well as health care organizations operating in other countries.
Number of pages: 12
