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as well as being clinical tools vital to providing effective and efficient care health records are also legal documents as an NHS foundation trust were governed by many laws and guidelines failure to adhere to our duties can have a huge implication for the trust including fines disciplinary action dismissal and in some cases criminal action but more importantly it can have a negative impact on our patients the Trust is transitioning to electronic health records that well still have to work with paper for a while yet so here are some practical points to keep in mind when working with paper health records the first thing to remember is that this is a team effort its everyones responsibility to ensure we have the right information about the right patient in the right place were all equally responsible if youre creating an entry in paper records you need to one print and sign your name to confirm your designation 3 where applicable write your General Medical Council PMC or Nursing an
