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'Aim of documentation should be to assist with patient care'


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.


Readers' comments (3)

  • I'm impressed you still get 3 days of face-to-face mandatory training - ours was diluted to online plus 1 x half day several years ago the main point of documentation:
    I couldn't agree more.
    I was 'brought' up as a student both with the mantra that 'if it's not written down it's not been done' but also, that a properly written care plan should be able to be evaluated with 'care as plan' plus comments on any deviations from the plan, or issues that had arisen (e.g. pain issues, abnormal obs plus action taken etc). It took about 2 days on placement to discover that no, you have to re-document everything that's in the plan stating you did it or it will be assumed not to have happened (the joys of a litigious society).

    Outcome - like you say, duplicating information e.g. obs; lots of time taken on paperwork reducing time on patient care; increasingly the culture of completing paperwork coming before any 'added extras' (or even some basics, like emotional support, mouth care (after all, you can't see if it's been done until something goes wrong - hmm)) is trained on down to the next generation of nurses.

    I remember a fantastic mentor I had, incredibly patient-centred, in a hospice setting, who I later met when I was an ICU nurse sent with equipment/to help SpR transfer an incredibly sick post-natal lady. As I entered the room to long series of requests from a desperate looking SpR & gynae SHO, midwife (my old mentor) was sat with notes, said hello & she couldn't remember my surname, & then when I gave it scribbled in the notes. Later, once lady ventilated, on inotropes and filtered in ICU (later died), I found in notes '2.54am SN x entered room'. When did that become more important than a clinical emergency (& for a nurse who didn't come from that ethos at all)??

    Paperwork also takes on more significance that the actual truth.

    As a patient (8hrs after should have been discharged but awaiting something in notes that no-one could tell me) heard a conversation about 'have you been on intentional rounding training yet' at the desk followed by a piece of paper arriving in folder at the end of the bed documenting 'rounds' that had apparently been done for whole 12-hr shifts (including meals I wasn't given) - no point complaining then as I'd be fighting paperwork.
    GP can produce documentary evidence that hospital notes are false, but they're still not changed as 'it's in the notes it must be true' (shame about the ongoing risk false information causes any time I'm admitted).

    As a patient, I'd rather have quality care, and that quality care be so reliable that the statement 'care as plan' in notes can be taken as the truth, than pages of documentation but compromised care.
    & as a nurse, I'd rather be providing that quality care than covering my back by writing it. (& exactly where would the NMC draw the line re: dishonesty when it becomes a patient's word against protective but falsified documentation??)

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  • My father died unexpectedly in hospital last year. It was only on reviewing his notes that I realised just how poor his care had been and how the lack of accurate fluid balances, an early warning scoring system not fit for purpose and tardiness in giving necessary drugs contributed to his death. The hospital acknowledged this.

    Nurses had spent more time filling in a care plan should he have a shower (which he never did have) than they did on correctly documenting his fluids. The intentional rounding charts just added to the confusion.

    As a nurse myself I am continually frustrated at the totally unnecessary duplication of paperwork that is forced upon us, nothing confirmed that view more than the death of my father.

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  • here in Australia I work in a private hospital all our documentation is electronic, fluid balance charts, obs charts, pathways, stool charts etc. We do have a comment section to most nursing unit managers like the nurses to document there as well as the pathway, what are your views do you think the nurses should document in the comment section if there are no variances? After the nurses have entered the obs it won't allow you to go further till you have completed a pain score.

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