Читать книгу The Nursing Associate's Handbook of Clinical Skills - Группа авторов - Страница 201

When considering record‐keeping, it is important to start with the Nursing and Midwifery Council’s (2018a) standards of proficiency for nursing associates that concludes that all nursing associates must keep clear and accurate records which are relevant to their practice, but while there is no specific professional document on keeping records, nursing associates must refer to The Code for guidance. Section 10 states that all nursing associates are to ‘keep clear and accurate records that are relevant to your practice’. The Code reminds the nursing associate that this applies to all records that are kept as part of the nursing associate’s role and is not limited to just patients’ records. The Code then lists a number of practical actions in subsections of Section 10.

The first subsection clarifies that every record must be made in a timely manner and as soon after the event as possible. This reminds the nursing associate that, as often as possible, records must be made at the time an event happens or as soon after it happens as possible. This is for several reasons but primarily as a record made while the sequence of events is fresh in the mind is probably going to be a more accurate record than one that is made later. This is just the same for a patient record as for an accident form or any other record. The second reason for making a timely record is a reminder that all records are made to improve patient safety. A record made in good time will help to prevent duplication of an episode of care. For example, if an action has been taken based on an old record rather than the latest episode of care, the patient could have the same drug administered twice or have the same referral made twice.

The next practical action listed in Section 10 is that the written record maintained by the nursing associate must ensure that all risks that have been identified or problems have been recorded along with the steps that have been taken to remedy these risks and problems. This action helps to ensure that other healthcare professionals who use the records have all the information that they need. One example of this is if the nursing associate identified that a patient was finding it difficult to mobilise with a walking stick, this would be recorded along with the fact that the patient had been referred to the physiotherapist. When the physiotherapist visits the patient, they can see clearly from the record what the problems were and why the referral had been made. Another application here that has to be considered is that if a patient was to make a claim of negligence regarding their care. The record relating to their care must clearly show that the nursing associate had identified the patient’s care need and reported it to the registered nurse in charge before recording this in the nursing notes. This would then demonstrate that a risk had been identified and appropriate steps had been taken to alleviate this risk.

The third practical action requires that all records must be completed accurately and without any falsification. It is not realistic to maintain records without ever making a mistake either by misspelling a word or by using a word that you did not mean to use in that context. Therefore, it will be necessary to mark a mistake or delete a word within a written record. This must be done by scoring through the mistake with a single line rather than obliterating the mistake with scribbles or correction fluid (liquid paper).