Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

LEADERSHIP ACADEMY

Would your records stand up to scrutiny?

  • 4 Comments

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.maxwell@london.com

  • 4 Comments

Readers' comments (4)

  • "You should remember the maxim that if it isn’t written down, it didn’t happen."

    I am really sick of the sloppy lies that are passed off as articles here. What utter rubbish. As you well know, Ms Maxwell, it is often written down when it didn't happen! But the tick box culture monster must be fed at all costs. The maxim should be, if it isn't written down....then maybe as a Nursing Director I should have known the reasons. You know; did I employ enough adequately trained staff and ENSURE that they had the staffing levels, resources, time and any other vital support to enable them to complete timeous, accurate records? Perhaps if you had an awareness of these issues, you might write an article that was a bit better informed and less smug.

    Unsuitable or offensive? Report this comment

  • Great stuff. So easy to pass responsibility down the line .How many Nursing Directors come and' work in the field' to see if what they expect of their nurses is actually humanly achievable?

    Unsuitable or offensive? Report this comment

  • Nurses,

    "If it wasn’t written down, it didn’t happen"

    This is frightening.
    Does that mean you have live in fear and write down every single thing you did, from talking to patients to how much medicine you prescribe in case "something happens" and you are thrown before a coroner or the NMC?

    How will you find the time to write everything down? You must be rushed of your feet anyway dealing with patients, providing cover, rounds and now there's revalidation to worry about.

    After all when can you document?
    At the end of a shift, when you're exhausted and just want to go home and simply sleep.

    During the shift when you're dealing with the patients and doing your rounds, dealing with handovers and simply working flat out?

    It isn't all that simple..
    I have read about Nurses here who simply are too rushed to be able to document anything.

    And how do you document everything?
    How can you remember everything?

    LOVE
    PDaveANGEL

    Unsuitable or offensive? Report this comment

  • Will dictate to PA : could not fully document contemporaneous notes due to prioritising patients care and supporting/assisting colleagues. Patients appear alive and improving as they're able to eat, drink, talk with staff, family + friends, uses mobile phone and watches tv, occasionally goes out for refreshments + fresh air ;)

    Unsuitable or offensive? Report this comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.

Related Jobs