ABSTRACT
Good record keeping is a mark of the skilled and safe practitioner, whilst careless or incomplete record keeping often highlights wider problems with the individual's practice. Poor records reflect poor patient care. The health professionals that follow these best practice guidelines will promote consistency and will improve and maintain standards that are essential for patient care and risk management. Thinking about the purpose of maintaining records will help the health professional to include the appropriate level of detail, content and form, and to write more clearly and accurately. There are a number of key principles that underpin good records and record keeping. Some of these relate to the content and style of the record in addition to the legal issues that a health professional should be aware of and take into account in record-keeping practice.
