Читать книгу The Nursing Associate's Handbook of Clinical Skills - Группа авторов - Страница 215

How could these five records be documented so that they are not speculative?

Mrs Jones has a high temperature
Mr Thomas has passed a large amount of urine this afternoon
Mrs Kowalczyk’s blood glucose is high, and she will probably have a stroke
Mrs Evans has diarrhoea; she must have eaten something bad
I think Mr Morgan is in pain

Speculation could also be interpreted as an attempt to gamble. Putting this into the context of record‐keeping, it would mean drawing conclusions with only part of the evidence; here, the nursing associate speculated and fails to consider facts. Gambling could mean that there is a 50% chance that the conclusion drawn is correct. This means that there is also a 50% chance that the conclusion drawn is incorrect; therefore, all records must be maintained factually and not speculatively. Similarly, speculation could mean ‘to assume’. Just because a person appears a certain way, an assumption must not be drawn. Again, records must deal in facts only. The next requirement of the NMC Code that relates directly to record‐keeping discusses secure storage.