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#NURCHAT

#NurChat - Does your record keeping pass the agency nurse test?

  • 2 Comments

Did you miss the latest #NurChat Twitter debate about documenting practice? Let us sum it up for you…

As an agency nurse I often come across varying examples of documentation and in many differing formats. It is quite a skill to navigate my way around it at times and I often feel for student nurses who are just learning and face the same challenges as me.

Documenting care is an important part of the nursing process but it does pose many challenges - this NurChat set out to explore some of these challenges. (You can find the full transcript of this debate on the NurChat blog).

The chat kicked off very quickly by NurChatters talking about the RCN record keeping guidance and how it is very good but there is no mention of digital record keeping. It was generally agreed that regardless of medium the same rules apply, with @IanIreland stating: “Standards should be no different between paper and electronic”.

@eileenshepherd stated “I agree the same principles apply. Nurses need to be confident electronic records are fit for purpose eg confidential”.

@0711maria joined the debate from a different perspective: “Hope its ok for patients to join in. I signed up to the summary electronic record and on my last 2 visits no records were found”.

It was then raised that standardised documentation should be implemented, as @Ramck001 tweeted “I’d love it if the whole of the NHS used a standard interchangeable system for documentation”.

@IanIreland replied “Why just NHS- at least 33%outside NHS”.

@TildaMC added “Even in the same hospital we have slightly different records. Only problem is one size often fits no one”.

NurChatters brought up the issue of who completes the documentation.

@TildaMC said “Think nursing assistants need to be more involved in documenting care as carrying out more and more”.

@IanIreland tweeted “Those who deliver should document”.

@Ramck001 said “As a multi disciplinary team we all have our place in a patients notes”.

@TaskerKaren added “Utopia of documentation is to document as soon as care is carried out by healthcare professional who carried out care”.

The use of tablets was raised @bazmoult stated “We need to leap forward with technology … secure tablets. Document care as it happens”.

@TaskerKaren said “We are in the process of developing e-records and will be using tablets to do at patient bedside/ near patient, can’t wait”.

@Ramck001 tweeted “And if they are Wifi capable we can look things up as needed. Digital BNF’s, NHS resources etc”.

NurChat then asked “Will digital records reduce the need for duplication of info? Will this help release time to care?”

@TaskerKaren responded “That is what I expect e-records to deliver - massive reduction in repetition”.

@IanIreland added “Once and once only needs to be our mantra”.

The importance of good record keeping was then raised.

@eileenshepherd stated “it is only when in court you realise how imp doc is from a legal view. Need to be reminded of this”.

@PhilipRABall tweeted “I recommend seeing an NMC hearing - as visitor - salutary experience”.

To conclude NurChat asked “Can we reduce time spent documenting? Or is it time well spent?”

@timcoupland replied “Mainly time well spent, but systems do need refining, GP systems do seem better”.

@TaskerKaren said “Meaningful doc is time well spent, if it means I (any nurse) can come care for your patient when you go home”.

@michellemellor3 added “Agree - reliable and accurate doc just as imp as care delivery to maintain continuity”.

There is no doubt in my mind that documentation will always be a hot topic for nurses; for me, it’s about quality not quantity - whether the records are digital or hand written. I have often had to wade through copious amounts of records to find the vital information that I need in order to be able to provide continuous care for my patients, but I have to agree with @TaskerKaren who tweeted: “We should be proud to document the excellent care we have given to a patient, it’s not an afterthought or extra”.

Does your documentation pass the agency nurse test? Can an agency nurse care for your patient from the records you maintain?

Teresa Chinn heads up NurChat for Newcross Healthcare Solutions.

Nurchat is a fortnightly Twitter chat exploring different topics that vary enormously.

Anyone can suggest a NurChat discussion subject simply by tweeting @NurChat or by visiting the NurChat blog.

  • 2 Comments

Readers' comments (2)

  • no ency any nurse caring for the patient accurate documentation ensures continuity of care for the most important person the PATIENT

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  • nursing notes have to be clear, complete and concise otherwise too much time, which could be spent on care, has to be spent navigating them. this can also cause stress and frustration in the reader trying to find the information required as well as leading to errors or omissions in care. they are also a legal record which must be a reliable source of information if they are required in the law courts.

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