Notes; Record Keeping PDF

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Lecture title Date

Record Keeping Mar 8, 2021

Define Record Keeping

“Good record keeping, is crucial to the provision of safe and effective care and an integral part of nursing and midwifery; not an optional extra to be fitted in if circumstances allow” (Nursing & Midwifery Council, 2009)

What are health record?

X-Rays, Scans and other imeges Patient held records Handwritten notes Electronic records Correspondence (including electronic communications such as emails and outgoing / ingoing text messages) Lab reports and printouts from monitoring equipments

Why is record keeping important?

For Patient Care…  Intrinsic to patient care  Ensures safe care delivery  Ensures continuity of care  Identifies risks and enables early detection of complications  Supports effective clinical decisions & judgments  Promotes better communication & sharing of information between members of the MDT For You…  Improves accountability  Helps to address complaints  Illustrates decision making process  Documentary evidence of services delivered To Wider Team…  Risk identification  Supporting clinical audit, research allocation of resources and performance planning  Addressing complaints or legal processes

Record Keeping & the law (Andrews and St Aubyn, 2015)

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But I’m too busy…

Record Keeping

Records provide evidence to our involvement with patients Increasingly nurses are being held to account for the standard of their records One of the most common causes of a legal claim arises because of a breakdown in communication between health professionals (Wood, 2010) Correlation made between poor record keeping and poor practice This is frequently being exploited in court to the detriment of the nurse in the witness box “Clash of cultures” between nurses and legal professionals Be mindful of protecting yourselves (and your employers!) against accusations

Sometimes nurses see record-keeping as an added pressure and a diversion from the demands of clinical care.  Can be a low priority for busy nurses and patients notes often poorly maintained (Jeffries et al, 2010)  However busy you are, lack of time to complete your records is not a defence against litigation (Wood, 2010)  Documentation is your only defence when your practice is assessed or decisions questioned (Andrews & St. Aubyn, 2015)  Records are rarely neutral – they either protect or condemn us professionally (Andrews & St. Aubyn, 2015)  REMEMBER…Legal outcomes are not based on the “truth” but on “proof” (Griffin, 2007)

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Nurses and midwives should keep clear and accurate records which are

Responsibilities      NMC Code of Conduct (2018)

Record Keeping: Key Principles

Section 10: Keep clear and accurate records relevant to your practice. This includes but is not limited to patient records. It includes all records that are relevant to your scope of practice. To achieve this, you must: 10.1 complete all records at all the time or as soon as possible after an event, recording if the notes are written some time after the event 10.2 identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who use the records have all the information they need 10.3 complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements 10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation 10.5 take all steps to make sure that all records are kept securely, and 10.6 collect, treat and store all data and research findings appropriately     

Paper Records: Best Practice

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Electronic Records

The 6 C’s of Record Keeping (Andrews & St. Aubyn, 2015)

Accountability (RCN, 2015)

relevant to their practice (NMC, 2018) Good record keeping is a vital part of effective communication in nursing and integral to promoting safety and continuity of care for patients and clients (RCN, 2015) Record keeping is intrinsic to patient care and the law places equal value on care and documentation (NCHC, 2014:5) Healthcare records are legal documents and can be called as evidence in a court of law You have legal obligations for the writing of, sharing of and storage of patient records Professional standards incorporated in the NMC Code of Conduct.

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Records must be completed accurately and without any falsification and provide information about the care given as well as arrangements for future and ongoing care. Records must be factual and objective When possible, the person in your care should be involved in the record keeping and should be able to understand what the records say. Abbreviations and jargon should be avoided. Must specify assessment, care planning, decision making and action taken or to be taken. (RCN, 2015) Records must written in indelible ink and be legible when photocopied or scanned. Must be signed (followed by full name and profession), dated and timed. Any later additions should be recorded at the end of the record and not squeezed into existing entries. Empty lines and / or spaces should be crossed through with a straight line A single line should be drawn through incorrect entries written in the records, with the date and signature of the person making the correction. Erasers and correction fluid must not be used (the original entry must still be visible). The same principles apply The system is designed to track changes and dates of entry Make sure you are clear on the formatting of the trust, for example ensure that you know how to record the type of contact (eg. Face to face, contact with patient)

Contemporaneous – right here…write now Continuity – tell the story of the patient’s “journey” Correct – clear writing, clear message, clear communication: clear conscience Claim – your records; your pin Candour – discontinue: document; share and treat Contain – write safe and store safe  Nurses are professionally accountable for ensuring duties they delegate to members of the nursing team

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Record keeping can be delegated to nursing students so care is documented When delegating record keeping, the registered nurse is required to ensure the student is competent to undertake the activity and that it is in the patient’s best interests for record keeping to be delegated If a student nurse completes nursing records then a registered nurse must countersign the entry, which documents agreement of the content Nursing staff have a duty to retain the confidential nature of patient records at all times. Disclosure of any information held in patient records is a serious offence

Summary (Griffith, 2016) The clinical record is a legal document. It demonstrates that you discharged your duty of care to the patients. If it is not documented it did not happen Any document that record any aspect of patient care is admissible as evidence in law. Always write factual, accurate and contemporary records Never write personal opinion, assumptions or inaccurate comments. Never falsify records or remove or erase entries Lecture topic quiz 1. 2. 3. 4. 5. 6. 7. 8. 9. 10....