RORY’s values

Setting the record straight

© 2013 MA Healthcare Ltd

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ver recent years nurses at all levels have received criticism from independent inquiries, health ombudsman’s reports, the Nursing and Midwifery Council (NMC) and the courts in relation to the quality of documentation and record keeping in patient records. Some of the resulting failings in care have been attributed to poor communication and poor quality of records. Further stipulations may emerge from the Francis enquiry. Record-keeping procedures are usually set by employers. The NMC recognises that, because of this, nurses and midwives may use different methods. However, the principles of good record keeping are well established (NMC, 2009), and should reflect the core values of individuality and partnership working. Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow. National programmes for the use of information communication technology and electronic record keeping are being introduced throughout the UK. Although electronic records are evolving, it is clear from nurses and midwives that paper-based records are still commonly used. NMC guidance applies to both paper and electronic records. Good record keeping, whether at an individual, team or organisational level, has many important functions. These include a range of clinical, administrative and educational uses such as: ■■ Helping to improve accountability ■■ Showing how decisions related to patient care were made ■■ Supporting the delivery of services ■■ Supporting effective clinical judgements and decisions ■■ Supporting patient care and communications ■■ Making continuity of care easier ■■ Providing documentary evidence of services delivered ■■ Promoting better communication and sharing of information between members of the multiprofessional healthcare team ■■ Helping to identify risks, and enabling early detection of complications ■■ Supporting clinical audit, research, allocation of resources and performance planning ■■ Helping to address complaints or legal processes. Documentation means ‘to give written information that is proof or support of something that has been done or observed.’ It is the written account of observations, the information the client, resident or family relates or states, the data you collect during care, and the care that you provide. A nursing/medical record is a collection of information about the person you are caring for.

British Journal of Nursing, 2013, Vol 22, No 19

It is a legal and confidential record with pertinent information related to the care provided. Simply put, a nursing/medical record is the record of all care that is provided. If it is not recorded, it did not happen. If it is recorded incorrectly, it happened incorrectly. This is why it is so important to be accurate when documenting. Equally, if it was not done, do not record it and never record on behalf of a colleague or allow them to record on your behalf. Four commonly used forms of particular importance are nurses’ progress notes, graphic sheet for vital signs, care plans, and activities of daily living sheets. Documentation provides crucial legal protection. Admissible in court, the patient’s medical record must be documented in an accurate, complete, systematic, logical, concise, and timely manner. Courts will view the documentation in the nursing/medical record as proof and verification to patient care. By showing that the individual under your care received quality, adequate care, a well documented record can, and will most likely protect you legally. A large number of directors of nursing have been attempting to design a model and process to audit the record keeping and care planning documentation of nurses, health visitors and midwives. How about we try and take a quality improvement approach to review nursing records and care plans, as opposed to a traditional audit approach? This would be undertaken through the adoption of the quality improvement approach, which mirrors ongoing work in the Patient Safety Programme, for example, the Scottish Patient Safety Programme (SPSP) and Clinical Quality Indicators used across the NHS in each of the four countries. The rationale for this proposal is that, despite the numerous audit projects undertaken on record keeping, there is little evidence this has produced sustained or widespread improvement in the quality of nursing records or care plans. Teams can use the model-for-improvement tool as the preferred approach, by carrying out small tests of change around the primary drivers of reliable records, reliable record keeping, culture, and education and awareness. From this, a number of process measures can be established for aspects of nursing records and care plans, and to help teams determine whether the changes they are making are leading to improvements in their nursing records and importantly, in their BJN patient care plans. 

Rory Farrelly NHS Greater Glasgow and Clyde Director of Nursing Acute Services Division

Nursing and Midwifery Council (2009) Record keeping. Guidance for nurses and midwives. NMC, London. http://tinyurl.com/9w9eqoy (accessed 8 Oct 2013)

 The views expressed in this column are those of the author

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