Nursing Documentation

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Nursing Documentation

• Peter Nicholas
• Education Development Practitioner, Surgical
  Division

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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)

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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

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Who reads nursing records?

• Nurses
• Patients
• Relatives
• Doctors
• Members of the MDT
• In effect EVERYBODY !!!

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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.

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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

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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)

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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.

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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

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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)

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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

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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

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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

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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

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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

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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