[The regulation of nursing record-keeping]. / La réglementation des écrits professionnels.

Record-keeping guarantees a permanent trace of a patient's treatment and the legal protection of the nurse. Legislation provides a regulatory framework. It is also a matter of professionalisation and improvement of practices.

[Ethical and Legal Aspects That Consider in the Medical History of the Elderly]. / Aspectos ético-jurídicos que considerar en la historia clínica de la persona mayor.

Nurses regularly use the patient's clinical history and we interact through it with multi and interdisciplinary team with the purpose of providing comprehensive care to the elderly. We make professional use of personal patient information with this interaction, as well we generate the nursing care plan and nursing records. We also perform comprehensive geriatric assessment and other specific registers aimed at elderly care, which have a clear impact on patient health care. The progress and regulatory complexity on the use of medical history, new strategies of the relationship in the context of care, based on bioethics, as well as the active role of nurses in the creation of information, makes necessary to review the ethical and legal issues surrounding this document, in this case, in elderly patients.

Think about your ink.

During my nursing career, I did what you do - blue or black for day shifts and red ink for night shifts. This allowed us to quickly find an entry as the night shifts stood out from the day entries.

Registros enfermeros. Contribución a la seguridad del paciente y a la visualización de la disciplina enfermera / Nursing records. Contribution to the security of patient and visualizing of the discipline of nursing

Los registros enfermeros conforman la historia de enfermería de un paciente con el objetivo de dejar constancia de la atención prestada y de la evolución de la persona desde la mirada holística que identifica la profesión. Estos registros tienen un contexto legal, profesional y de seguridad que deben cumplir. También a través de la escritura se puede inferir la visión que de la profesión tiene el profesional/escritor. En este artículo se analizan algunas expresiones extraídas de registros enfermeros de unidades de cuidados paliativos tomando como referencia los elementos contextuales nombrados. Se concluye que se debería prestar más atención a esta actividad, que es una obligación profesional y un derecho del paciente, para dotar a los registros enfermeros de información objetiva, clara, sin ambigüedades ni interpretaciones erróneas, y que refleje la aportación específica de la enfermería a la sociedad (AU)

The nursing records conform the clinical history of a patient with the aim to bring evidence of care provided by professional as well as to bring evidence of evolution of a person from a holistic point of view that identifies the profession. These records have a legal, professional and security contexts that ought to be fulfilled. In addition, with help of record keeping it is possible to infer a vision of the profession that was transmitted by the author. This article discusses the qualitative data based on various expressions extracted from the nursing records of palliative care units, taking as a reference the contextual elements that were named above. It concludes that it’s important to give more attention to this activity as it presents a professional obligation and belongs to patient’s rights. The current research stresses the importance to have the nursing records updated with the objective information, clear, without ambiguities or misinterpretations, and which can evidence the specific contribution of nursing to the society (AU)

'Fear of litigation is compromising care'.

Care homes are allocating far too much time to paperwork at the expense of face-to-face patient care because they are fearful of being blamed or sued if their records are not up to scratch, a social reform charity said.