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Educational input to improve documentation skill

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VOL: 97, ISSUE: 08, PAGE NO: 35

At the time of writing, Melanie Fisher, BSc, RN, PGDE, was practice development nurse, Newcastle upon Tyne Hospitals NHS Trust. She is now senior lecturer (clinical skills) at the School of Nursing, University of Northumbria at Newcastle

The UKCC has stressed that documentation is a fundamental part of nursing, midwifery and health visiting practice (1998). As well as acting as a vehicle for improving communication and promoting continuity of care, good documentation is the mark of a safe and competent practitioner. However, poor records cause problems, as many court cases have shown.

The UKCC has stressed that documentation is a fundamental part of nursing, midwifery and health visiting practice (1998). As well as acting as a vehicle for improving communication and promoting continuity of care, good documentation is the mark of a safe and competent practitioner. However, poor records cause problems, as many court cases have shown.

Setting the record
Record-keeping mirrors the overall standard of practice and, like it or not, also reflects the skill of the practitioner (UKCC, 1998). Litigation in general, as well as in health care, is increasing (Donaldson, 2000) and the impact of this has been felt in health care circles. In response to this, several significant issues were identified from the complaints and incidents collated within the trust. A project was then initiated to examine standards of record-keeping.

The Newcastle upon Tyne Hospitals NHS Trust is one of the largest in the country, following the merger of two former acute trusts. Variations in practice, both in terms of the documents in use and standards of record-keeping, needed to be addressed.

Data was collected from a sample of 364 records of recently discharged patients. Samples were taken from all specialties in the four hospitals across the trust. The documents examined included assessment profiles, care plans, pathways, communication/evaluation documents, transitory charts such as observation records, fluid balance and various clinical assessment documents.

The results showed that there were areas of good practice and areas in need of improvement and development. Problems included partially completed documents, incorrect patient identification, and documents which appeared to be missing from the records.

The above issues have obvious implications for both the trust and for individual practitioners. A professionally written, contemporaneous record is likely to be the only evidence of a patient's treatment and, as such, is crucial to the defence should litigation be brought. Similarly, in the event of a patient complaint, good documentation is integral to the investigation and subsequent satisfactory resolution.

In order to address these issues, the trust developed an educational programme for staff with the aim of raising awareness about the importance of good record-keeping and its legal significance. The programme is a one-and-a-half day workshop that concentrates on the legal and professional aspects of record-keeping. Whether using care plans, care pathways or electronic records, the key principles of good documentation apply (Box 1).

Initially, the programme was developed using the NHS training guide Just for the Record (NHS Training Division, 1994) and originated as an in-house workshop. Additional exercises and presentations were gradually added to make the programme innovative and interesting. In order to drive the message home, guest speakers were enlisted including lawyers, and nurses who had attended a coroner's court, either to give evidence or to support other staff. Members of the trust's management team involved in quality assurance, complaints and incident handling also contributed to the workshops.

Organising the programme
The first day of the programme begins by allowing staff to explore their feelings and beliefs about record-keeping. It shows how documenting care fits into patient care management. Staff then complete a case study analysis, which examines a patient's nursing record, including the plan of care and evaluation/communication record. They are asked to analyse the documents as if they were answering a real complaint which had led to litigation.

This analysis exposes participants to the consequences of incomplete record-keeping and allows them to reflect on their own practice. This inevitably sparks discussion about accountability, the legal status of records, case law and standards for good practice. Acts of parliament affecting records are discussed, including the Data Protection Act (1984, 1998) and Access to Health Records Act (1990).

The first half of the session focuses on the theoretical aspect of documentation, complemented by the second half which is more interactive and practical. This is due in part to the guest speakers. Two nurses are invited to tell the group individual accounts of their experience in a coroner's court.

The first account is by a nurse who, in her capacity as a nurse manager, was required to support a member of nursing staff who was called as a witness following the unexpected death of a patient. The outcome of the case was largely determined by the nursing documentation, which in this case was incomplete, resulting in undeserved blame being placed on the nurse. This was as a direct result of incomplete records, from which observations and subsequent actions were omitted.

The second account is from a former ward sister who intuitively perceived that a complaint might be imminent following an incident, the death of a patient and the relatives' subsequent reaction. She documented in detail the events leading up to and surrounding the incident in the expectation that she would be involved in a subsequent investigation. Her concise documentation helped the case to reach a satisfactory outcome.

The final presentation is delivered by a member of the trust management team and relates to the handling of complaints and incidents. The focus is on good practice and provokes discussion about the role documentation plays in the investigation and subsequent outcome of complaints.

Overall the programme is designed to raise awareness of good record-keeping by exposing staff to the wider issues.

In order to apply the knowledge acquired in the first half of the programme, participants are asked to perform an audit exercise in their own clinical areas in which local standards of practice are measured using the data collection tool designed for the initial trust-wide audit. They are expected to present the results to the group on day two of the programme, normally held six weeks later. The emphasis is on peer support and staff are asked to adopt a 'no blame or shame' attitude. It is common for nurses to identify similar problems and good practices in relation to their audits. The discussion and sharing of ideas gives programme participants the chance to examine areas of practice that are effective and to develop a similar strategy for their own areas.

The programme has evolved into its present format over a five-year period and is now tailored to meet the needs of the directorates throughout the trust. Written evaluations confirm that the programme is successful because of its structure and, in particular, because it involves guest speakers.

Although the subject matter can be very serious, the delivery of the programme is designed to be relaxed and informal, providing an opportunity for participant interaction.

Initially attendance at the early sessions was primarily by nurses at D and E grade, whereas now all grades of nurses attend, as well as other health care professionals and non-nurses. The sessions provide a forum for participants to explore common issues, often creating interesting debates.

The programme continues to evolve and demand is constant. In future it is hoped that the workshops will attract a wider interdisciplinary audience. We are working collaboratively with the clinical effectiveness and audit department to strengthen the relationship between the workshops and record-keeping practice. Above all, the programme has enabled us to illustrate the theoretical issues relating to documentation and their direct influence on practice in a way that is innovative and creative.

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