Good record keeping helps to protect the welfare of patients by promoting high standards of clinical care, allowing better communication between members of the whole health care team, giving an accurate account of treatment, and allowing the ability to detect problems at an early stage.
With so many benefits, it would seem no nurse would have a problem with record keeping, but they do. Many struggle to find the time to keep good records and do not consider it as important as other activities.
Hands-on care might seem more important than records, but medico-legal experts and the NMC say that if a nurse does not put down something in their notes then legally it did not happen – making it very hard to deal with complaints. Records can be used as evidence by the NMC’s Fitness to Practise committees in cases of complaints made against nurses.
Good record keeping is an indication of a skilled and safe practitioner, and just as true is the fact that careless or incomplete record keeping often reveals wider problems with an individual’s practice. There is also a benchmark on record keeping contained in the Essence of Care document – the government’ tool to improve the quality of nursing care.
While there is no single model or template for records, the NMC suggests records should:
- Be factual, consistent and accurate
- Be written as soon as possible after an event has occurred
- Be written clearly and to prevent text being erased
- Be written in such a manner that any alterations or additions are dated, timed and signed, allowing the original entry to still be read clearly
- Be accurately dated, timed and signed
- Not include abbreviations, jargon, meaningless phrases, and irrelevant speculation
- Be readable on any photocopies
- Be written, wherever possible, with the involvement of the patient or their carer
- Be consecutive
- Identify problems that have arisen and the action taken to remedy them
- Provide clear evidence of the care planned, decisions made, care delivered and information shared.
Patients also have rights of access to health records, governed by the provisions of the Data Protection Act 1998. It gives patients and clients access to their paper-based and computer-held records.
As records are becoming increasingly held on computers, the principle of confidentiality of information held about patients is just as important for this as in all other records, including those sent by fax. A nurse is professionally accountable for making sure that whatever system is used is fully secure.
Updated: September 2006