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'Using your personal judgement is easier said than done when it comes to record keeping'

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When Elaine received constructive criticism on her record keeping attempt, she was able to step back and take away some key learning points - and not give up!

During my first week on a community placement, I joined my mentor on a home visit to a client whose care was being transferred from the crisis to the community mental health team.

Whilst confidentially means that I can’t go into detail, suffice to say that events happened during the visit that made us concerned about the person’s safety over the weekend. Back at base, we discussed this with members of the MDT.

Enthusiastically, I offered to draft the record of the visit and discussion. I set about clearly stating the purpose of the visit, subjective and objective observations, summarising assessment tool results, risks, discussion, preventative and supportive factors in place and - last but not least - the plan.

All in all, I was quite pleased.

Predictably, a lot needed to be changed! It’s testament to just how excellent feedback can be, that constructive comments made me want to reflect on how to improve my skills, rather then feel embarrassed, or worse still, reluctant to volunteer again.

So, where had I gone wrong?

Well, I’d been rather vague, and assumed that someone reading the record would come to the same conclusions as the team – I hadn’t spelled out everything that had been considered before the decision was made.

I also realised that because I hadn’t been confident I’d accurately remembered a point, I’d ended up missing it out all together! Finally, I hadn’t thought through how the information would be used - assessment findings were in flowing prose, rather than in helpful quick to scan lists.

Lessoned learnt, my plan for future records is to:

  • Clearly record everything used to make a decision, as well as the decision itself
  • Make sure that I’m confident, and ask for clarification, spellings, and for other statements that can be documented
  • Record information in the best format to help whoever needs to find it, find it

All in all, a good learning experience! I learnt that in practice, the NMC record keeping guidance that “you should use your professional judgement to decide what is relevant and what should be recorded” is easier said than done.

I also developed a deeper appreciation of just how effectively the MDT had worked together to build up a picture of the person, their situation, and the depth and quality of decision-making.

Elaine Francis is a second year Mental Health Nursing student at University of Greenwich. She tweets at @eformation


Do you struggle with record keeping?

Nursing Times Learning has a 2-hour online learning unit that will get your record keeping up to scratch and in-line with national standards:

Clinical Record Keeping

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