Record Keeping

Susan Lillyman, Pauline Merrix

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317905806
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Effective record keeping is a sign of safe and skilled Nurses and Midwives and is a legal requirement for all Healthcare professionals. This pocket-sized guide provides you with the tools to write clear and concise records.

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Records

As noted in the introduction a health record is:

• A permanent form of information relating to an individual’s physical or mental health
• A record where the individual can be identified from that information
• Made by a health professional in connection with the care of that individual

The Records Management NHS Code of Practice (2006) states that all practitioners working within the NHS are responsible for any records they create or use whilst caring for an individual. These documents are then public records.

Records that identify a living individual are referred to as personal data. These can also include information where a person can be identified from the data in conjunction with other data/information that the professional holds.

This can include:

• Name
• Address
• Age
• Race
• Religion
• Gender
• Physical health
• Mental health
• Sexual health

■ Why are Records Needed?

Good records are needed in order to:

• Communicate information to other professionals and facilitate continuity of care
• Keep a record of the day to day care given to patients
• Provide a chronological account of the patient’s life, illnesses
• Identify who did what and to what effect for the patient
• Enable early detection of changes in the patient’s condition
• Evaluate the patient’s progress
• Enable patients to have greater involvement in their care and demonstrate a patient centred approach to the care received
• Demonstrate patient safety and quality of care
• Demonstrate professional accountability
• Support clinical audit and clinical governance
• Inform medico-legal investigations and aid in the management of enquiries and complaints
• Inform research

■ Types of Records

The Records Management NHS Code of Practice (2006) suggests there are a number of different forms of records; these may include:

• Handwritten or electronic clinical notes
• A&E, birth and all other registers
• Theatre registers and minor operations lists
• Patient/parent held records
• Emails
• Letters to and from other health professionals
• Laboratory reports
• Radiographs and other imaging reports and outputs and images
• Printouts from monitoring equipment
• Incident reports and statements
• Photographs/slides and other images
• Microfilms
• Videos
• Tape-recordings, video and cassettes
• Text messages
• Scanned records

■ What Makes a Good Record?

• Clearly identified patient/service-user name
• Arranged in chronological order with the most recent on top
• Legible handwriting
• Entries signed with the nurse’s name and job title printed alongside the first entry
• Student’s entry countersigned by a qualified practitioner
• Made as near to the time of the episode of care as possible and before the relevant staff member goes off duty. (This fulfils the legal requirement that records are contemporaneous.)
• Accurate and recorded in such a way that the meaning is clear and easy to understand
• Factual and do not include unnecessary abbreviations
• Facilitates communication in a full and effective way with other professions, ensuring they have all the information they need about people in your care
• Changes to entries follow set procedures
• Readable when photocopied or scanned. (The use of black ink is best.)
• Based on professional judgements (see below)
• Objective
• Written so as to be compliant with the Race Relations Act (1976) and Disability Discrimination Act (2005)

■ What Makes a Poor Record?

• Inaccurate information
• Illegible and poorly structured writing
• Subjective comments that cannot be supported by facts and accompanied by irrelevant or offensive speculations
• Unauthorised or retrospective changes to the record
• The use of sarcasm or humorous abbreviations to describe patients in your care. (These could be viewed as disrespectful comments.)
• Notes that are not comprehensive enough, with omissions or gaps in the record
• Anonymised recordings
• Jargon and unnecessary abbreviations

■ Recording Professional Judgements

Including professional judgements should help you to decide what is relevant and should be recorded.

These should include:

• Use of evidence based methods of assessment and reviews
• Critical thinking in relation to care given
• Evidence based practice for diagnosing and care planning
• High quality information that justifies the approach to care taken
• Information received and given to the patient about their care and treatment
• Risks or problems that have arisen with the action taken to deal with them
• Informed consent gained, explicit or implied, ensuring an entry is made if consent is withheld by the patient and the reasons for this
• Identifying the outcome of care given

■ Being Objective in Your Records

Objectivity is another important feature of good record keeping. State facts from what you see, feel, hear and smell. By recording these four sensory observations you are attempting to distinguish between fact (objectivity), which is what actually happened, and opinion (subjectivity), which is what might have happened.

Examples of what you See:

• Bleeding, urine colour, pallor, sweating, deformities, bruises, oedema, sores/lesions, redness, body fluid colour, pupil reaction

Examples of what you Feel (to the touch):

• Crepitus, dampness, localised heat/cold, pulses

Examples of what you Hear:

• Complaints, moaning, breathing, heart sounds

Examples of what you Smell:

• Faecal odours, fruity odours, foul smelling drainage, and alcohol breath

Examples of Objective, factual statements:

• No complaints or pain or discomfort
• Eyes closed and respirations regular
• Thrashing about in bed
• I.V. Dextrose 5% infusing at 60 drops per minute with site clear and no redness

Examples of Subjective statements:

• Had a good day
• Usual night
• Appears restless
• I.V. running well

■ Using Abbreviations

The use of abbreviations is discouraged by the Nursing and Midwifery Council and other professional bodies as they can prove difficult for patients/service-users to understand. In addition, they can be misinterpreted by other professions. If abbreviations are used in a record there must be an accompanying glossary which has been approved by the appropriate professional body or the NHS local Trust.

■ How to Amend Entries if Needed

• Alterations must be accompanied by your name, job title and with a signature and date alongside the alteration.
• The use of Tippex or similar correcting techniques is strongly discouraged.
• The original record, as well as the alteration, must be clear and auditable.

■ Electronic Records

When creating and using electronic records you must:

• Password protect any files/computers
• Always log-out of any computer system when work on it is finished
• Never leave a terminal unattended and still logged in
• Not share logins with other people
• Not reveal passwords to others
• Always clear the screen of a patient’s information before viewing another
• Ensure entries you make in electronic records are clearly attributable to you
• Abide by the Data Protection Act 1998

■ Storage of Records

The Secretary of State for Health and all NHS organisations have a duty under the Public Records Act 2005 to make arrangements for safe keeping of records. There is an appointed ‘Keeper of Records’ who is answerable to parliament. Within the Trusts the chief executives and senior managers are personally accountable for the management of records within their organisation. All individuals who work within the NHS are responsible for the records that they produce.

To meet legal requirements:

• Adult records must be kept for at least 8 years
• Paediatric and maternity records for at least 25 years
• Psychiatric notes up to 20 years
• General health records 8 years after the conclusion of treatment or death

The storage of records is an important feature of the record keeping process. Records must be returned to locked storage as soon as possible and should not be left in offices, cars or individual homes. You should not leave computer records on screens where they might be viewed by unauthorised staff or members of the public.

■ Patient Held Records

Patient held records were first introduced in the National Health Service in 2001 following a recommendation made in the National Service Framework for Older People. Within this system, the patient has custody of their records for on-going care but the records will eventually be stored with the National Health Service when treatment is no longer required or the patient dies. Parent and patient held records are currently confined to use in the midwifery and primary care services.

■ Destruction of Records (shredding or incineration)

Before any destruction takes place it must be ensured that:

• Actions are clearly minuted by the appropriate personnel. This could be a records committee or relevant health professional body
• Confidentiality is maintained
• The value of the records for long term research has been assessed

Unofficial destruction of records by any health care professional is a serious matter that can result in disciplinary procedure.

Access to records

■ For the Patient

There is a formal proced...

Table of contents

• Cover
• Title
• Copyright
• contents
• INTRODUCTION
• RECORDS
• ACCESS TO RECORDS
• PREPARING FOR THE LEGAL DEFENSIBILITY OF RECORD KEEPING
• CONFIDENTIALITY
• CONSENT TO TREATMENT AND RECORD KEEPING
• ETHICS, ACCOUNTABILITY AND RECORD KEEPING
• MAINTAINING YOUR SKILLS FOR RECORD KEEPING
• RELEVANT LEGISLATION
• OTHER RECORDS
• CONCLUSION
• KEY REFERENCES
• USEFUL WEBSITES