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How to get to grips with record keeping

Keeping accurate records is vital to patient care …

Balancing the admin and the practical aspects of nursing can be difficult.

If you want to get more qualifications, however, you’ll inevitably be required to take on more responsibility - especially record keeping.

Managing documentation in a busy hospital can be daunting at the best of times but it is as important as caring for patients - in fact it’s a vital part of caring for patients.

Nursing documentation includes assessment, planning, implementation and evaluation. There should be clear evidence of the care planned, the decisions made, the care delivered and the information shared, according to The Nursing and Midwifery Council (NMC).

The Data Protection Act 1998 defines a health record as “consisting of information about the physical or mental health or condition of an identifiable individual made by or on behalf of a health professional in connection with the care of that individual”.

The NMC states that nurses should keep clear and accurate records of the discussions they have.

Nurses should also document the treatment and medicines given and how effective these have been.

The NMC is producing a new standard for record keeping, which will be published in January 2013.

In the meantime, here are some essentials for good record keeping:

  • Legible handwriting
  • Signed, dated and timed entries. For paper records, the person’s name and job title should be written alongside the first entry
  • Entries must be in chronological order and recorded as close to the actual time as possible
  • Records should be accurate and clear
  • They should be factual and not include unnecessary abbreviations, jargon or irrelevant speculation
  • Nurses should use professional judgement to decide what information should be recorded
  • Clinicians should record assessments and reviews, providing evidence of arrangements made for future care
  • Records should identify any risks or problems that have occurred and show the action taken to deal with them
  • All records should be kept secure, and originals should not be destroyed or tampered with
  • In the unlikely event that nurses have to alter records, the original documentation should be clearly amended with the name, job title, signature and date of the amender
  • Where appropriate, the patient/service user or carer should be involved, and should understand the language can be used
  • Records should be readable when photocopied or scanned
  • Nurses should not use coded expressions of sarcasm or humorous abbreviations to describe the people in your care
  • Never falsify records

The Foundation of Nursing Studies chief executive Dr Theresa Shaw stresses the importance of record keeping and how it is as important as practical aspects of nursing. “We are lobbying to look at ways it can be made simple,” she says.

Documentation can be seen as a boring aspect of the job. “It is often seen as a burden,” she adds. “We need to move away from that.”

Dr Shaw recognises that if record keeping is not implemented properly, it can affect nurses’ careers but more importantly, she says it can be “detrimental to patients”.

Registered nurse Elizabeth Ferris says it is possible to be concise yet comprehensive. She says: “I try and make notes contemporaneously. If a patient complains of chest pain, I will deal with the situation and then document it at the time, rather than waiting to the end of the shift.”

She adds that her logical approach makes it easy for other staff to understand. “It ensures that physiological parameters are available at a glance for other staff,” she says.

There are, however, many instances when nurses slip up. While mental health nurse Paula Marie was at Windy Knowe Nursing Home by Springcare, she was accused of making vital errors, including failure to record which drugs she administered and why and noting information retrospectively.

Ann Moira faced charges of failing to keep adequate notes whilst working as a caseload manager of the Community Night Nursing Service by Wirral PCT, including failure to sign, date or record the time of the entries made, not recording who had administered an injection of Nozinan and claiming that another staff nurse was present.

The Queen’s Nursing Institute director Rosemary Cook admits that there are inevitable incidents where people haven’t recorded data correctly. She believes the solution for this is electronic record keeping or the electronic patient record (EPR). Ms Cook adds that it has existed for a long time but there is still resistance to it. “It needs to be instant,” she says.

By using handheld computers, nurses can record events in real time, rather than leaving it until the end of the day. She says the more people that are inputting data, the better. “Records need to be clear, practise being brief, timely as possible, respectful and meaningful,” Ms Cook says.

The Florence Nightingale Foundation chief executive Elizabeth Robb agreed with Ms Cook that record keeping is essential. “The purpose is to keep a clear record of what has happened to the patients and the reasons why nurses responded in the way they did,” she says. She adds that if you delegate fundamental care, it is recorded accurately and acted upon effectively.

Ms Robb says the reasons for our actions, the result and how you measure the outcome are important in record keeping, but she admits that doing this is a challenge.

This is indeed a challenge, and one which has certainly increased with the rise in assessments.

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