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14 January, 2003

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½urses are subject to increasing scrutiny regarding their record-keeping. Legislation such as the
Human Rights Act 1998 and the Data Protection Act 1998 has increased the profile of, and access to,
health records (Dennemeyer, 2000; Sainsbury Centre for Mental Health, 2002), while patients are
increasingly willing to complain about their care. Whether complaints are resolved by health care
providers or settled in court, comprehensive records are essential.

It is important, therefore, that nurses keep abreast of legal requirements and best practice in record-
keeping. The Code of Professional Conduct (½MC, 2002a) advises that good note-taking is a vital tool
of communication between nurses. It states that nurses 'must ensure that the health care record for
the patient or client is an accurate account of treatment, care planning and delivery. It should be
written with the involvement of the patient or client wherever practicable and completed as soon as
possible after an event has occurred. It should provide clear evidence of the care planned, the
decisions made, the care delivered and the information shared'.

It is significant that allegations concerning shortcomings in nurses' record-keeping were the second
most common category of hearing brought before the UKCC in 2000-2001 and were surpassed only by
allegations of abuse (½MC, 2002b; UKCC, 2001).

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The cost to the ½HS of litigation rose from £2.3bn in 1998 to £4.4bn in 2001 (½ational Audit Office,
2002). Litigation is already regarded as an occupational hazard for medical staff, and it is estimated
that at least one in three other health professionals will be involved in some kind of legal proceedings
at some point in their career.

Law courts adopt the attitude that if something is not recorded, it did not happen and, therefore,
nurses have a professional and legal duty to keep records. The ½MC (2002c) states that
documentation should demonstrate:

- A full account of the nurse's assessment and care planned and provided for the patient;

- Relevant information about the condition of the patient at any point;

- Measures the nurse has taken in response to the patient's needs;

- Evidence that the nurse has understood and honoured the duty of care, has taken all reasonable
steps to care for the patient and that any action or omission has not compromised patient safety;

- A record of any arrangements the nurse has made for the continuing care of a patient or client.

½urses face new issues and problems each day and regularly make decisions on patient care. Each
decision is potentially subject to review with the public's increasing awareness of their rights and
tendency to litigate. Amid the stress of a working day, it is easy to see how record-keeping might be
seen as a chore that gets in the way of patient care. However, it is an integral part of care.

½urses must allocate time for both hands-on care and documentation, as it is the two together that
constitute total patient care. If record-keeping is seen as a chore, there is a risk that the
documentation will fall short of the standard expected of a professional.

A nurse who has cared for hundreds of patients could not possibly remember details about the care
provided to a particular patient several years - or even several weeks - later. However, the
circumstances are likely to be fresh in the memory of the patient making the complaint. Good
documentation can therefore be a vital means of recollection for nurses faced with litigation. Detailed
and substantial evidence is likely to be influential in such circumstances; nurses whose memories of
events are poor and who have not documented their actions clearly may find their position
compromised. Having good quality records to refer back to enables the nurse giving evidence to relate
as precisely as possible what happened.

Long before a legal case becomes a formal hearing, the nursing notes will have been read and studied
and an impression formed regarding the relative professionalism of the author. If records are clearly
unprofessional it is easier to extrapolate that the same lack of professionalism would be reflected in
attitudes towards patient care.

Any notes or records taken in the course of a nurse's work are a potential legal document and could
be used in court. If they contain judgemental, vague or unsubstantiated information, it becomes
difficult to maintain professional credibility in court. It is the job of a patient's lawyer to undermine a
nurse's case by casting doubt on that nurse's credibility. Lawyers are familiar with court cases and
professional hearings - two scenarios that may be extremely intimidating for those who are not.

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½urses should also bear in mind, when compiling records, that their colleagues rely on the information
they record when taking over a patient's care. This can resolve any uncertainty over how much to
write in patients' notes. The frequency and content of entries is determined both by a nurse's
professional judgement and local standards, but an acid test is: 'If a nurse were coming to care for a
patient for the first time, what would they need to know?' Colleagues should be able to look at a
nurse's notes and continue caring for the patient in a seamless continuum. If a named nurse was
unable to return to work, then from the patient's point of view this should make no difference to the
care they receive.

½urses are also professionally accountable for ensuring that any duties they delegate to unregistered
staff are undertaken to a reasonable standard. For example, if a nurse delegates record-keeping to
students or nursing assistants, she or he must ensure that they are adequately supervised and
capable of carrying out the task. The nurse is accountable for the consequences of those records and
such entries must be clearly countersigned.

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By adopting the following habits, nurses should avoid problems related to record-keeping:
- Get into the habit of using factual, consistent, accurate, objective and unambiguous patient
information;

- Use your senses to record what you did, such as 'I heard', 'felt', 'saw', and so on;

- Use quotation marks where necessary, such as when you are recording what has been said to you;

- Ensure there is a reasoned rationale (evidence) for any decision recorded, for example, denying
access to a visit from children;

- Ensure notes are accurately dated, timed, and signed, with the name printed alongside the entry
(initials should be avoided);

- Follow the SMART model (Specific, Measurable, Achievable, Realistic and Time-based) or similar
when planning care;

- Write up notes as soon as possible after an event and, by law, within 24 hours, making clear any
subsequent alterations or additions;

- Document any objections you may have to the care that has been given;

- Do not include jargon, meaningless phrases (for example 'slept well'), irrelevant speculation, and
offensive subjective statements;

- Write the notes, where possible, with the involvement and understanding of the patient or carer
(½MC, 2002c).

Expressions such as 'had a good day' should not feature in isolation. ½otes should explain why the
patient had a good day - for example, if a relative visited or the patient was lively and interacting with
staff and other patients (Dimond, 1999). There are also misconceptions around the use of subjective
words such as 'appears'. This cannot be used as a factual observation such as 'appeared unsteady on
his feet' - a patient either is or is not unsteady on his feet. However, such an expression could be used
where the facts would be impossible to establish, for example a confused and inarticulate patient who
'appeared to be experiencing auditory hallucinations'. The nurse could not be certain what the patient
was experiencing, but would need to elaborate and describe the behaviour that led to this conclusion.

Errors should be corrected by putting a single line through the incorrect statement and signing and
dating it. If records are used in evidence, it must be clear what was originally written and why it was
changed, therefore correction fluids should not be used.

Sometimes professionals may face conflicting ethical pressures - for example it may be considered
'kinder' not to keep informing a patient with dementia that they are in hospital under a section of the
Mental Health Act when they repeatedly ask where they are. Provided that nurses know what they are
doing and why, and are prepared to justify it, this should not cause undue legal problems (Andrews,
2002; ½MC, 2002c; Department of Health, 1999). Ultimately, professional nurses must be able to
justify why they have taken a particular course of action.

The ½MC's position on abbreviations is that they should not be used (½MC, 2002c). However, a
number of everyday medical abbreviations are used appropriately and safely, such as BP (blood
pressure). To write these in full each time would add considerably to the time taken to complete
records. However, there are dangers in the use of abbreviations. For example 'PT' could mean patient,
physiotherapist or part time; 'BD' could mean twice or brought in dead. Misunderstandings can be
avoided by generating an agreed list which is reviewed regularly. This list should be attached to
patients' records (Andrews, 2002; ½MC, 2002c; Dimond, 1999).

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Vigilance is required to ensure high standards in record-keeping, whether records are in written or
electronic form. The audit of patient documentation is a facet of risk management, and can help to
promote quality (½MC, 2002c) as it means standards can be assessed and areas for improvement
identified (Dimond, 1999).

Maintaining good quality records has both immediate and long-term benefits for staff. It can directly
benefit them, for example in respect of safety, by promoting the early identification and appropriate
treatment of potentially violent patient behaviour. In the long term it protects individuals and teams
from accusations of poor record-keeping, and the resulting drop in morale. It also ensures that the
professional and legal standing of nurses are not undermined by absent or incomplete records, if they
are called to account at a hearing.

Good record-keeping promotes better communication as well as continuity, consistency, and

efficiency, and reinforces professionalism within nursing. For the sake of patients and colleagues - as
well as their own protection and peace of mind - every nurse should get into the habit of recording
their actions and observations accurately and professionally.

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