Record keeping is an essential part of care practice for nurses and others, yet is often undervalued.
At times such as complaint investigation or review of reflective practice, poor record keeping can cause much debate and consternation, and can often let down care that has been delivered.
Inconsistencies in recording, poor spelling, misunderstood reporting and poor hand writing add to the mix of poor communication.
Good record keeping is not only an essential nursing skill, but an absolute priority in view of accountability for care.
There have been several attempts to introduce systematic record keeping in the UK. The Single Assessment process, in the early 2000s, along with electronic patient records in health settings, have failed to deliver any real change across the system.
As yet, we have not fully implemented a system which reduces the burden of form filling, provides accurate, timely, accessible record and robust assessment, known to be the cornerstone of good care for older people.
“We continue to hoard large, unwieldy files in large containers and laboriously use them for audit and complaint management”
Paper care records seem archaic at a time when we are seeing adoption of assistive technologies to better manage patient care. Yet we continue to hoard large, unwieldy files in large containers and laboriously use them for audit and complaint management, trawling through great tomes of information. Imagine a tap on the keyboard and a dashboard of information for every resident, home, region and business on your screen.
A system that supports your memory by promoting you to do the routine test and monitoring, generate care plans that help you spend time to care through more time with residents, teaching, supporting families and time to supervise and support your colleagues.
Imagine being able to run reports about quality, progress and critical incidents, a handover note at each shift, a far cry from a rumpled piece of paper and handwriting which is impossible to read, dug out of a pocket.
Driven by the need for state-level data about care and costs per resident, and linked to a national reimbursement system, Care Homes in North America (Canada and USA) have been long using electronic care records.
The requirement to have such systems in place has been the driver, but the benefits for care have been a consequence.
This has proved to be an important part of care home nursing through improving compliance with requirement of state quality directives. More importantly, residents getting the right care in the right place at the right time.
This year, the CQC 5 year strategy states clearly that relying on robust data has to be part of ensuing compliance with registration requirements, and would support better compliance, outcomes and care experience.
Like the UK, North America has been experiencing rising costs and reduced funding on top of the rising demand to meet the needs of an aging population.
North America’s nursing homes were forced to embrace technology when they were mandated, by law, to submit state required data through a national assessment process. The Resident Assessment Instrument Minimum Data Set (RAI-MDS) was introduced electronically over 20 years ago.
Implementation of an electronic care record system has enhanced nurses’ use of the nursing process.
The systematic assessment, planning, goal setting and evaluation of nursing interventions provides a simple framework well used and known, but in a methodical and consistent way.
”Time is saved by easily and quickly accessing key information about residents”
The comprehensive approach and ability for a system to prompt you to review and refine care planning is often useful in a busy and changing clinical environment such as a care home.
Having a system that is responsive and negates the need for arduous thumbing through of large paper files, means that at an individual and unit level nurses have access to the most up to date clinical information for residents. This helps with care transfer between systems such as hospital and the home, and visits by external care experts, such as the general practitioner. Time is saved by easily and quickly accessing key information about residents, where consent has been given.
The electronic environment allows nurses to set up care plan triggers and provides a drop down library that helps with care planning.
Using a library based on best available evidence and best practice saves time and can be personalised for each resident. Some have taken a further step in maximising the potential of what electronic care planning has to offer by connecting to web-enabled hand held mobile devices for all care staff who can then enter care delivery information and always have an up to date care plan at their finger tips, allowing them access to every resident’s needs at any time.
This ensures that care plans are used and the care that is planned is delivered - then no one can say “we couldn’t get to the care plan”. This has considerably improved the relationship between all care givers and emphasises the value and role that everyone has to play in the care of vulnerable residents with fluctuating needs who require complex care interventions.
What needs to be highlighted is that the technology should not replace care, but enhance it. Time and resource savings, which are inevitable, should be invested back into residents.
So how could an electronic care record system work here and how could it support care and support CQC compliance?
- Nurses have data at their finger tips to make educated decisions regarding medication side-effects, vital observations, behavioural signs of distress, etc.
- Consolidated data is available when needed to communicate with GP; decreasing unnecessary, costly (both financial and emotional) transfers to hospital
- When data gets entered at point of care it is more accurate – not having to rely on carers memory or scribbled notes
- Nurse action can be taken immediately by avoiding delay in relaying potentially critical observations
- Simultaneous multi-disciplinary access to the care plan ensures individual needs, hobbies and interests are known, providing awareness to meet people’s needs and wishes.
- When staff don’t have to record duplicate information on paper forms and don’t have to manually summarize communications, they have more time to spend with the residents implementing care and providing social interaction
- Leadership has the ability to easily audit and action failings and omissions in care.
- Date, time and author stamping of entries prevents bulk charting early or at end of shift.
- Dashboards and Reporting provides insight into incomplete or inconsistent records daily.
- Leadership can monitor and take action proactively ensuring continuous quality Improvements
- Single point of entry ensures consistency throughout the record.
- Carers are able to identify people’s needs and legibly record any care provided.
- Next actions are prompted by best practice with alerts and triggers
- Nurses time is used more efficiently, they can delegate with confidence since they are able to easily monitor, evaluate and interpret results.
There is growing interest in finding new ways of working: releasing time to care, unburdening clinical staff from administrative duties to provide safer, person centred care which can be easily monitored at an individual, unit and home level.
Maybe past failures in supporting a systematic approach to record keeping have helped us learn that without it we are not providing the best for those who need it most.
Using an electronic, standardised approach to record keeping has multiple benefits and had we entered a brave new world sooner we would have robust data today for commissioning, planning education, reporting and compliance with national standards.
Maybe that day is about to dawn.
Deborah Sturdy, Visiting Professor Bucks New University; Melissa Jackson, Director of Education PointClickCare