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4 Record keeping

Figure 4.1 Mixing opinion and fact.

Figure 4.2 Illegible writing.

Figure 4.3 Removing an error.

Figure 4.4 Designation and signature.

Figure 4.5 Counter‐signature.

Background

 Part 10 of the Nursing & Midwifery Council Code (NMC 2018) requires clear and accurate records to be kept.

 Record keeping is a key part of our communication within the interdisciplinary and multidisciplinary team (RCN 2017).

 Record keeping allows for communication of assessment, care planning, interventions, treatments, and evaluation.

 Poor record keeping has been linked to poor care and raised patient safety concerns (Francis 2013).

 While record keeping is key to providing continuity of care it should also be noted that any document can become a legal document once requested by the court (Dimond 2015).

Influencing Factors

 Critically unwell and/or hypovolaemic patients.

 Those who are agitated, confused or confrontational.

 Those in status epilepticus or having regular seizures.

 Needle phobia.

Professional Approach

 Time pressures – these pressures can result in documentation being delayed and thus it will not be as accurate as when recorded directly after the fact.

 Time pressures – these pressures can also cause handwriting to be illegible and result in typographic errors when using electronic records.

 Insufficient training on the documentation used can result in mistakes and/or omissions.

 Healthcare workers must remain up to date with training on record keeping, data collection, and storage and be aware of legal requirements about these.

Equipment

 The correct document to record the specific actions taken.

 Access codes may also be required.

Procedure – Standard Documentation

 Ensure that documentation is performed as soon after the fact as possible (RCN 2017).

 Avoid unnecessary abbreviations or abbreviations that could have multiple meanings, e.g. MS could refer to multiple sclerosis or mitral stenosis.

 Avoid unnecessary and/or inappropriate comments, such as mixing opinion and fact (Dimond 2015) (Figure 4.1).

 Avoid slang, jargon, derogatory, and any other comments that could be classed as unprofessional.

 Provide accurate and concise details of the intervention.

 Provide details on any future care required, i.e. next dressing change, evaluation of current care.

 Read through the work and ascertain if it would be understandable to the person who was provided with care (RCN 2017).

 Ensure that it is legible (Figure 4.2).

 If any errors are noted on written documentation, cross through the words with a single line (Figure 4.3).

 Provide date, time, and location of intervention.

 Provide designation and signature (Figure 4.4).

 Ensure a counter‐signature is provided where required (Figure 4.5).

Procedure – Writing a Statement

You can be asked to write a statement as a witness to an incident, if you are under investigation, if you are raising a concern, or if you have a grievance. Professional bodies provide guidance and support on how to write individual statements but below are some key points:

 Provide your name, position, date, and subject heading – this includes any reference numbers.

 Highlight what this is connected to and the date and time of the incident. The introduction should also state your role in the incident.

 Provide a clear and full description of what occurred and when. Providing a clear account of an event can be challenging if a significant amount of time has elapsed. It is recommended that if you are involved in an incident that concerns you, you raise the concern and write the statement at that time.

 Highlight who was involved – this may include other colleagues, patients, family members, friends, significant others, and other members of the general public.

 Highlight any other factors that could have impacted on care provision such as short staffing, acuity of patients, caseload, any additional responsibilities.

 If possible, leave for one to two days before re‐reading and submitting to the relevant personnel.

 If keeping an electronic copy, make sure it is encrypted.

Red Flag

  Patient safety should always be ensured before documentation.

  If you cannot read the patient’s records, this needs to be escalated and the person involved will need to rewrite to ensure safe, effective, care provision.

  If care is not recorded, either written, typed, or in a voice file, it will be considered as not undertaken. This can result in duplication, which can be detrimental to patient care, e.g. medication administration.

References

1 Dimond, B. (2015). Legal Aspects of Nursing, 7e. Harlow: Pearson.

2 Francis, R. (2013). The Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationary Office.

3 Nursing & Midwifery Council (2018). Professional Standards and Practice of Behaviour for Nurse, Midwives and Nursing Associates. London: Nursing & Midwifery Council.

4 Royal College of Nursing (2017). Record Keeping the Facts. London: Royal College of Nursing.