CAREERS

Accurate records help keep patients safe and protect staff against legal action, writes Nicola Davies

Getting documentation right treating people traumatised by war, and those with noma, a gangrenous infection of the face. ‘One particular patient was so shy he would keep his face covered. ‘Nursing him, showing that he was accepted, brought about a beautiful change; he became confident and mischievous. It was rewarding to see his healing,’ she says. She has seen the change in patients offered cleft lip and palate repairs they could never otherwise afford. Her experiences have brought a fresh appreciation of the NHS. ‘Working with Mercy Ships involves different ways of doing things. You learn to be adaptable, more cost effective. ‘It has stimulated me to get involved in local prisons, and visit orphanages,’ she says. Taking health care to the poorest people in the world is extraordinary, and has helped to make me a better nurse by broadening my experience and skills.’ Carol Davis is a freelance journalist

Between medication administration, care tasks and communication with colleagues and patients’ families, documentation often gets put on the back-burner. However, it is a critical aspect of nursing care that provides a precise account of your actions that is vital for your legal protection and that of your employer. Below are a few suggestions to ensure your documentation is accurate and timely.

documentation available, consider using an established structure such as SOAP (see box).

Patient identification

Record with caution

Ensure you are recording details for the right patient. This might seem obvious but an error can have serious consequences. Verify the patient’s name, age, primary diagnosis and room and bed number. If you inadvertently record details for the wrong patient, document this on their chart before charting correctly for the right patient.

Information required

Ask yourself: ‘If this patient was transferred elsewhere, what would staff need to know?’ Communicate what is necessary in a clear, concise manner. If pertinent information is omitted, uninformed decisions could be made, which could leave the employer exposed to legal action.

Structured recording

Most healthcare organisations use a standard format for nursing records, whether paper or online. If there is no structured

Holiday pay NHS Employers has released guidance on the calculation of holiday pay for those who work overtime or whose weekly working hours can vary. Holiday pay is currently calculated using the previous 12 weeks as a benchmark. Agenda for Change does include provision for holiday pay to be calculated by taking account of regular ‘additional to contracted’ hours. The new guidance says a number of other payments could be taken into account in calculating holiday pay, including performance pay. Also, holiday accruing from bank work should be accounted for separately from the main employment holiday pay. See tinyurl.com/NHSEHPay Information sharing The Department of Health has published a leaflet emphasising the importance of sharing information with professional colleagues and other team members who

Be accurate

When writing notes, document only what you have seen, heard or felt yourself. Be accurate and provide quantitative information. If relevant third-party information is passed to you, document the source alongside the information.

Consider how your notes may be read by someone with no nursing experience. Abbreviations might be misinterpreted; use only those approved by your institution and known to other healthcare professionals. Nursing documentation is an important tool to plan patient care and justify clinical actions. It is also a first line of defence in a legal situation and should be rigorously maintained to protect yourself professionally. Nicola Davies is a health psychologist and writer

SOAP documentation structure Subjective – patient reported data Objective – nurse observed data or symptoms Assessment – report of patient assessment Plan to address patient issues

are caring for a patient. The guidance sets out five rules for information sharing as part of a person’s direct care, as well as an overview of the main factors that nurses must consider regarding information sharing in day-to-day care. It also outlines support you can expect from your organisation on more detailed issues associated with making the right decision about when and how to share data. Visit tinyurl.com/IS5rules Bursaries The RCN Foundation Worshipful Company of Needlemakers Educational Bursaries, worth up to £1,000 each, are available annually to assist with funding learning and development activities that enhance patient care in one or more areas. Entry for the bursaries is by application form, which can be submitted until January 21. For more details go to tinyurl.com/RCNeedlemaker

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Getting documentation right.

Between medication administration, care tasks and communication with colleagues and patients' families, documentation often gets put on the back-burne...
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