It is essential that you provide evidence when you document patient care
Record-keeping is done to a variable standard throughout the health service. Some people do it really well, and some do it very poorly.
It seems that some nurses think that if they communicate things to a colleague orally, they don’t need to write things down. They think if they do a fantastic handover, they only need to do cursory record-keeping. But this isn’t the case. While communication is one aim of record-keeping, just as important is accountability, explaining what you observed and the actions you took.
When I was a director of nursing, I was sometimes called to support nurses giving evidence to the coroner’s court. This is still the most likely place that nurses will have to give an account of what they have done, but many don’t think about it, and when they go, they often have to give an oral explanation of what happened as the records are insufficient.
However, if it is just a recollection, the nurse can have a different version of the event to the relatives or from other staff, and the nurse’s version may not be accepted by the court or maybe put down to a difference of opinion.
You should remember the maxim that if it isn’t written down, it didn’t happen.
It is really important to use records to explain why you didn’t do something as much as why you did do something.
You need to document the evidence and what you did with it. Sometimes nurses reach a conclusion, for example: “the patient was confused” but don’t explain why they believe that to be true. You need to include what you see, hear and any physical examination and how you interpreted it and the action you took, rather than just including a judgement. Bear in mind an action can be to continue to observe.
Some people put in observations, but miss the conclusion. Some people go straight to the conclusion.
Don’t just make value statements, such as “patient slept well”. Talk about how you evidence that. Just because they didn’t call you doesn’t mean they slept well.
Nurses often forget that they are accountable to four different parts of the law. They are accountable to their profession for maintaining the standards in the Nursing and Midwifery Council’s code of conduct, and also to the public under criminal and civil law for their patients’ safety. Nurses are also accountable to their employer under employment law, and need to keep records according to the employer’s policy as well as the NMC guidance.
How to maintain good records
● Write down what you see, hear and any physical examination (including vital signs). Provide evidence
● Don’t just write “the patient slept well” when you haven’t evidenced why
● Don’t just put the “patient was confused” without explaining why you reached this conclusion
● Put down what you observe, the conclusions you draw from that and the action you took
● If it wasn’t written down, it didn’t happen
Elaine Maxwell has been a nurse for over 30 years and has worked as a clinician, a senior manager and researcher. She provides independent consultancy on professional issues and quality management. Follow her on Twitter @maxwele2 or email Elaine.firstname.lastname@example.org