Nursing Documentation

Peter Nicholas Education & Development Practitioner, Surgical Division

Why is there a need for nursing documentation?

Record keeping is an integral part of nursing and midwifery practice. It is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow.
(Nursing & Midwifery Council April 2002)

Good record keeping promotes:

High standards of clinical care Continuity of care Better communication & dissemination of information between members of the MDT An accurate account of treatment, care planning and delivery of care The ability to detect problems at an early stage

Who reads nursing records?

Nurses Patients Relatives Doctors Members of the MDT

In effect EVERYBODY !!!

What is expected of a registered nurse?

The quality of your record keeping is a reflection of the standard of your professional practice.
Good record keeping is a mark of a skilled and safe practitioner.

Record keeping should demonstrate:

A full account of your 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 continued

Record keeping should demonstrate:

That you have taken all reasonable steps to care for the patient and any action or omission on your part have not compromised their safety A record of arrangements you have made for the continuing care for the patient (NMC 2002)

Unqualified staff
Nurses are professionally accountable for ensuring that any duties they delegate to members of the MDT who are not registered with the NMC, are done to a reasonable standard. If a student, CSW or adaptation nurse completes nursing records, then a registered nurse must countersign the entry, which shows that they agree with the content.

Writing should be Factual, consistent and accurate Written as soon as possible after an event has occurred, providing current information on the care & condition of the patient Written clearly in such a manner that the text can not be erased Written so that any alterations or additions are dated, timed and signed in such a way that the original entry can still be clearly read Accurately dated, times and signed with the signature printed alongside the first entry Not include abbreviations, jargon, meaningless phrases, irrelevant speculation or offensive subjective statements Written wherever possible with the involvement of the patient or carer and in terms that the patient can understand Readable on photocopies

Legal Matters
Nursing records can be used :
in court of law by the Health Service Commissioner To investigate a patient complaint By the NMC in case of complaint of professional misconduct

The approach to record keeping that the courts of law tends to adopt is that if it is not recorded, it has not been done
(NMC 2002)

Access to records
Data Protection Act 1984
Regulates the storage and protection of patient information held on computer

Access to Health Records Act 1990

Gives patients the right of access to manual health records about themselves that were made after 1st November 1991

Nursing Documentation
The Nursing Process a systematic approach to nursing which comprises a series of steps which, most commonly, are referred to as assessing, planning, implementing and evaluating. Roper 1990

Assessment
Utilise Roper, Logan and Tierneys 1980 Activities of Living Model Waterlow risk assessment Trust nutritional assessment Moving and Handling Assessment

All of the above should be completed on admission and reviewed on transfer

Planning
Can be core care plans or hand written which reflect your nursing assessment. If using core care plans they must be personalised.

Implementation
The act of giving care

Evaluation
The frequency of entries will be determined by your professional judgement and local standards at least twice per shift is recommended Exercise particular care and make more frequent entries when patients present more complex problems, show deviation from the norm, require more intensive care than normal, are confused and disorientated or generally give cause for concern You must use your professional judgement to determine when these circumstances exist

Audits
By auditing records NMC states you can assess the standards of records and identify areas for improvement and staff development Benchmarking documentation has been identified by the DoH as one of the key targets within benchmarking