Record Keeping for Nurses and Midwives: An essential guide

Amanda Andrews, Bernie St Aubyn

• Publisher: M Publishing
• Year: 2020
• Print ISBN: 9781905539253
• eBook ISBN: 9781907830259
• Topic: Medicine
• Subtopic: Nursing

For too long, record-keeping has been considered an 'add-on' to nursing care and records are often hurriedly completed at the end of a shift, almost as an afterthought. Yet, as this helpful guide demonstrates, good record-keeping is a professional obligation and a vital part of nursing care. Records provide a channel of communication between healthcare professionals and evidence of what care was given, and when and how it was given. This evidence can help protect both nurses and patients, especially if complaints are made and an issue goes to court.The authors have over ten years' experience of training nurses on the principles of record-keeping and encouraging them to reflect and think critically and professionally about their records. They begin by introducing the general principles of record-keeping, and then explain how to ensure that records are well documented and court-proof (in other words, accepted by the legal profession). They also discuss record-keeping in practice and the increasing use of electronic patient record systems. Finally, there is a quiz to test your record-keeping knowledge.

Chapter 1

Introduction to record keeping principles

The records we keep are an important communication tool, providing continuity of care between different healthcare professionals. They demonstrate whether or not a nurse is using evidence-based practice and they also provide evidence that can be used in court about the care a nurse has delivered. So there is a fundamental need for nurses to keep records.

Regardless of whether the information is handwritten or inputted electronically, you need to consider both how you are writing and what you are writing. Remember ‘if it’s not written down, it wasn’t done’.

This section will introduce you to the key principles of record keeping, which can be applied across all healthcare fields and used with any paperwork or electronic template.

Record keeping and the four stages of the nursing process

Each of the four stages of the nursing process has specific documentation associated with it.

Firstly, the patient is assessed and information is recorded and various risk assessments are completed.

Secondly, a care plan relevant to the individual patient’s problems is written or printed. This outlines the care to be given by all the nursing staff to mitigate the problems that have been identified for the patient (as the nursing process involves taking a problem-solving approach).

Thirdly, the care is carried out and various charts are used to record and monitor the patient’s progress.

Finally, the care that has been delivered is evaluated and this evaluation is recorded on an evaluation sheet or discharge summary.

The need for good-quality records

We have established that there is a need for records and that the quality of your records has an impact on the quality of your clinical practice. Good-quality records promote high standards of clinical care by facilitating:

•Continuity of care

•Good communication and dissemination of information between members of the multidisciplinary team (MDT)

•An accurate account of treatment, care planning and delivery of care

•The ability to detect problems at an early stage

•The ability to respond to complaints or legal processes.

Good-quality records should include:

•A full account of the patient’s assessment and the care you have planned and provided

•Relevant information about the condition of the patient at any given time and the measures you have taken to respond to their needs

•Evidence that you have understood and honoured your duty of care

•Evidence that you have taken all reasonable steps to care for the patient; and no action or omission on your part has compromised their safety

•A record of arrangements you have made for the patient’s continuing care.

Underlying record keeping principles

Now we’ll consider the underlying principles of record keeping that can be applied to all clinical areas of practice. No matter where you work, or what type of records your organisation keeps, applying these principles will keep your patients safe and keep you safe.

Records need to be:

•Legible

•Signed (print name and job title alongside signature)

•Dated and timed

•Accurate and clear

•Factual, avoiding:

-Unnecessary abbreviations

-Jargon

-Meaningless phrases

-Offensive statements

-Irrelevant speculation.

Legible and signed

You need to own your records and you do this by signing them. However, not everyone’s signature is recognisable or legible so best practice dictates that you also print your name alongside your signature. In order to identify yourself professionally, some organisations will also ask you to write your designation and your NMC PIN number ...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Preface
• Chapter 1 Introduction to record keeping principles
• Chapter 2 Court-proofing your documents
• Chapter 3 Record keeping in practice
• Chapter 4 Electronic patient record systems
• Chapter 5 Test your record keeping knowledge
• References