04 April 2018

Not documented? Not done.

There is a lot of information about good documentation in nursing. Whilst it is often related to the legal importance of accurate record keeping, it is essential to remember that documentation is also a good way of communicating with your colleagues. Further still, it can contribute to the assessment of care and decisions made about ongoing care, as well as treatment for the service user.

The NMC code states that clear accurate record keeping is an obligation of any nurse and as such, should be considered as an important part of the care we give to our service users.

There are few standardisations of documentation models and, therefore, when working in different areas of care, it is vital to be aware of local policies relating to documentation. As we move further into the electronic age, an understanding of the systems used in the area in which you are working is paramount for accurate and consistent documentation to be maintained.

Whatever system you are using, there are clear rules you must follow, to ensure that your documentation is accessible. It is important that others can understand what you have recorded, and what that means for the service user you have been caring for.

NMC code:

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 (NMC 2009)

Keep clear and accurate records relevant to your practice (NMC Code 2015)

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:

  • Complete all records at the time or as soon as possible after an event, recording if the notes are written sometime after the event.
  • 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.
  • 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.
  • 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.
  • Take all steps to make sure that all records are kept securely.
  • Collect, treat and store all data and research findings appropriately.

The NMC refers to many types of records - not just the services user’s notes. It is important that we use many forms of record keeping and these can include e mails, incident reports, videos, photographs, text messages and tape recordings of telephone conversations.

Golden rules:

  • Legible hand writing.
  • Be objective.
  • Be factual consistent and accurate.
  • Avoid gaps in medical records.
  • Avoid Jargon and abbreviations.
  • Document time and date clearly.
  • Document as close as possible to time of event or care given.
  • Focus on facts not speculation.
  • Do not change or alter others documentation if you need to amend your writing draw a clear line through it and sign and date any changes.
  • Date and sign all entries.
  • Records should follow a logical sequence allowing those caring for the patient after you to be clear of care given and care required.
  • Document things not done with clear rational especially if it is deviates from an agreed plan.

Countersigning:

Registered nurses can delegate record-keeping to care assistants, assistant practitioners and nursing students. Whilst, they can document their care, a countersignature is required until the member of staff is deemed competent. However, a registered nurse should not countersign if they have not witnessed the activity. All nurses should be aware of local policy with regards to countersigning documentation (RCN 2017)

Care plans should be written wherever possible with the involvement of the service user, in terms that they can understand, and include:

  • Patient-focused, measurable, realistic and achievable goals
  • Nursing interventions reflecting best practice
  • Relevant core care plans that are individualised, signed, dated and timed. (Marsden 2015)

Tips for evaluating care in a useful and meaningful way

  • Appears comfortable – slept well
    • Try to identify this using the person’s perspective i.e. what the patient states Patient states’ Pain was better so had a good night’s sleep’
  • No problems with wound
    • Be specific -Size of wound noted, any inflammation noted any dressings any diagrams attached.
  • Patient fell
    • Be specific – Was it witnessed? What did the person say happened? What were your actions – Has care changed following fall.
  • Very confused
    • Be specific i.e. confused in time, place and person what behaviour was the person showing to make you conclude they were confused.
  • Uncooperative
    • ​​​​​​​Be specific – How were they uncooperative Were they verbally uncooperative what behaviour were they displaying i.e. shouting or swearing when you were trying to help.
  • Dizzy at times
    • ​​​​​​​Give more detail when did they state they were dizzy were observations recorded what follow up is planned? I.e. doctor informed for review tomorrow.

The Royal Marsden Manual of Clinical Nursing Procedures: , Ninth Edition Chapter Two ‘Assessment and Discharge’ Edited by Lisa Dougherty, Sara Lister and Alexandra West-Oram

© 2015 The Royal Marsden NHS Foundation Trust. Published 2015 by John Wiley & Sons, Ltd.

www.nmc-uk.org/code accessed March 2017

RCN 2017 Delegating record keeping and countersigning records 3rd edition Publication code 006 134