Patient documentation is crucial but must be kept simple, precise, concise and cohesive, otherwise it does not support patient care, argues Jayne Parker
Recently I spent three days attending my trust’s mandatory and statutory training on topics covering a range of issues from manual handling and basic life support, to Datix reporting. It also included the executive welcome to the trust - all sensible, but rather rushed and without due justice given to most topics.
One of the themes discussed was professional record-keeping. Rather predictably this covered accountability to the Nursing and Midwifery Council, to our employer and to ourselves. It stated that records - both legal and potentially legal - had to be legible, accurate, concise, signed and dated.
As was expected, the sentiment “if it’s not written down then it’s not been done!” was made clear. All of this is quite correct, but there was never any mention that the documentation might actually be useful in the care of our patients. Even when I look at the NMC’s Record Keeping - Guidance for Nurses and Midwives, the first bullet point is “helping to improve accountability”. Is this really the most important reason for keeping records and documentation? Wouldn’t a better first point be “to assist with and inform the care of patients and clients”?
On any day I complete, or add to, perhaps 10 separate documents for each patient: observation chart, fluid balance, skin care, falls assessment, care plan, nursing notes and so on.
To the best of my knowledge, none of my documentation has ended up being used in any legal proceeding, but I would hope at least some of my writing had informed, guided or assisted with the ongoing care of patients. When I take over care of a patient I read the care plan and nursing notes, together with the doctor’s, physiotherapist’s or dietitian’s notes to inform my care.
Being dyslexic I have a double disliking of documentation and, if possible, I would like to do the minimum - preferably with a built-in grammar and spelling checker to help.
Unfortunately, all our unit’s documentation is still paper-based, with forms ranging from smart heavyweight printed booklets down to the A4 sheet of paper that has been photocopied a few too many times and has lost any legibility it may once have had.
Furthermore, many forms potentially duplicate what is recorded on others: is it necessary to write on the nursing care plan the patient’s blood pressure was 140/70 when it is also recorded hourly on the observation chart? It’s disheartening to record in neat, legible handwriting onto an over-copied piece of scruffy paper with illegible columns you’re sure no one will ever read.
Using the well-worn maxims of safe, effective and holistic, documentation that is simple, precise, concise and cohesive can help with all these three aspects and in the process become far greater than just “accountability”. Should this not be the standard that nursing documentation is judged by?
Jayne Parker is a staff nurse at East Surrey Hospital.